
LIBRARY OF CONGRESS, 

Chap*.„\„. 'Copyright No. 



3helf„,iAA(o 



*$' 



UNETED STATES OF AMERICA. 



Pathological Technique 



A PRACTICAL MANUAL FOR THE PATHO- 
LOGICAL LABORATORY 



BY 

FRANK BURR MALLORY, A. M, M. D. 

Assistant Professor of Pathology, Harvard University Medical School; Assistant 

Pathologist to the Boston City Hospital ; Pathologist to the Children's 

Hospital and to the Carney Hospital 



JAMES HOMER WRIGHT, A.M., M.D. 

Director of the Laboratory of the Massachusetts General Hospital ; Instructor 
Pathology, Harvard University Medical School 




*. * 



WITH io 5 ILLUSTRATIONS 



H 



PHILADELPHIA 
W. B. SAUNDERS 

925 Walnut Street 
1897 



37 : 

)^1 



Copyright, 1897, 
By W. B. SAUNDERS. 



ELECTROTYPED BY PRESS OF 

WESTCOTT & THOMSON, PHILADA. W, B. SAUNDERS, PHILADA. 



r 
i 



TO 

HENRY F. SEARS, A.M., M. D., 

WHO BY HIS LIBERALITY FIRST RENDERED POSSIBLE PATHOLOG- 
ICAL RESEARCH IN BOSTON, AND BY HIS PERSONAL 
WORK ADVANCED AND STIMULATED IT, 

THIS BOOK IS RESPECTFULLY DEDICATED BY 

THE AUTHORS 



PREFACE. 



This book is designed especially for practical use in 
pathological laboratories, both as a guide to beginners and 
as a source of reference for the advanced. We believe that 
the book will also meet the wants of practitioners who have 
more or less opportunity to do general pathological work. 

Every autopsy presents for solution a problem which may 
be simple or complex. The known quantities are certain 
clinical symptoms and physical signs ; the unknown quan- 
tities are not only the gross and microscopic lesions that 
may or may not have given rise to the symptoms and signs, 
but also the etiology of the lesions and the order of their 
sequence. The solution of the problem often requires the 
highest skill in post-mortem, bacteriological, and histo- 
logical technique, but in its solution lies the fascination of 
pathological work. 

It has seemed advisable to us to present, so far as possible, 
a consecutive statement of the methods employed in solving 
the various problems that arise, so as to avoid the repetitions 
that necessarily occur when the three usual divisions of the 
subject are separately considered by different writers. It 
is hoped that this method of presenting the subject will 
bring the student to the realization that the mechanical per- 
formance of a post-mortem examination and the inspection 
of the gross lesions constitute usually only the beginning 

of the solution of the problem, which should be investigated 

11 



12 PREFACE. 

bacteriologically, histologically, and chemically as far as our 
present knowledge will permit. 

We should particularly advise the routine bacteriological 
and histological examination of the more important organs 
in all suitable cases. Naturally, the autopsies in which the 
lesions are due to a single etiological factor are the most 
valuable and instructive for a clear understanding of the 
pathological processes present. 

Besides the methods of post-mortem examinations and 
of bacteriological and histological investigations connected 
with autopsies, we have added the special methods em- 
ployed in clinical bacteriology and pathology. 

In the parts devoted to Bacteriology and to Pathological 
Histology we have not endeavored to make an exhaustive 
collection of methods and formulae, but rather to select 
those which have been found of the greatest service in 
practical work. 

To Dr. A. H. Wentworth, Assistant in Children's Dis- 
eases in the Harvard University Medical School, we are 
indebted for the sections on the Blood and on Malaria, and 
for the notes in regard to Lumbar Puncture. 

Boston, August, 1897. 



CONTENTS. 



PART I. 

POST=MORTEM EXAMINATIONS. 

Introduction, 17. — Instruments, 18. — General Rules, 21. — Suggestions to 
Beginners, 23. — Private Autopsies, 24. 

I. EXTERNAL EXAMINATION OF THE BODY. 

Inspection of the Body as a Whole, 26. — Special Inspection of the Different 
Parts of the Body, 27. 

II. INTERNAL EXAMINATION OF THE BODY. 

Opening of the Abdominal Cavity, 27. — Inspection of the Abdominal Cavity, 
29. — Opening of the Thorax, 30. — Inspection of the Pleural Cavities, 31. — 
Opening of the Pericardium, 32. — External Inspection of the Heart, 32. — 
Opening of the Heart, 33. — Removal of the Lungs, 37. — Organs of the Neck, 
39. — The Abdominal Cavity, 40. — The Spleen, 41. — The Gastro-intestinal 
Tract, 41. — The Liver, 44; The Kidneys and Adrenals, 45. — The Pelvic 
Organs, 47. — Removal of the Brain, 50. — External Examination of the Brain, 
55. — Section of the Brain, 56.— Virchow's Method, 58; Pitre's Method, 59. — 
Removal of the Spinal Cord, 60.— The Eye, 62.— The Ear, 63.— The Naso- 
pharynx, 64. — Examination of New-born and Very Young Children, 65. — 
Restitution of the Body, 67. 



PART II. 

BACTERIOLOGICAL EXAMINATIONS. 

I. BACTERIOLOGICAL APPARATUS. 

Steam Sterilizer, 70. — Hot-air Sterilizer, 70. — Blood-serum Coagulator, 70. — 
Gas-stove, 71. — Test-tubes, 71. — Hypodermic Syringes, 71. — Cornet Cover- 
glass Forceps, 71. — Dropping-bottles, 71. — The "Platinum Wire" or "Loop," 
72.— Bacterial Filtering Apparatus, 72. — Wire Baskets, 72. — Tin Cups, 73. — 
Thermo-regulator, 73. 

13 



14 CONTENTS. 

II. CULTURE=MEDIA. 

The Preparation of Test-tubes, 74. — Preparation of Culture-media : 
Bouillon, 75 ; Glucose Bouillon, 76; Agar-agar (Plain), 77; Glucose Agar- 
agar, 79. — Glycerin Agar-agar, 80; Gelatin (Plain), 80; Glucose Gelatin, 81 ; 
Blood-serum (Lofflers Mixture), 81 ; Litmus-milk, 85; Potato- cultures accord- 
ing to Bolton, 85 ; Dunham's Pepton Solution, 86. — The Filling of Test-tubes, 
86. — Sterilization of Culture-media, 87. 

III. BACTERIOLOGICAL EXAMINATIONS AT AUTOPSIES. 

Cover-glass Preparations, 89. — Staining Methods for Cover-glass Preparations : 
Gram's Method of Staining, 91 ; Stain for the Bacillus Tuberculosis (Gabbet's 
Method), 92; Welch's Method of Staining the Capsule of the Pneumococcus, 
93; Curry's Method of Staining the Capsule of the Pneumococcus, 93. — Ex- 
amination by Cultures, 94. — Method of Preparing Cultures on Blood-serum, 
94; The Inoculation of Animals, 96. 

IV. THE METHODS OF STUDYING BACTERIA IN CULTURES. 

1. Cover-glass Preparations from Cultures, 98. — The Staining of 
Spores, 100.— -The Staining of Flagella, 100 : Loffier's Method. 102; Pitfield's 
Method, 103; Bunge's Method, 103; Van Ermengem's Method, 104. — 2. 
Methods of Obtaining Pure Cultures, 105. — Method of Isolation of a 
Bacterium in Pure Culture from a Mixed Growth, 107 : The Plate Method of 
Petri, no; Esmarch's Method of Roll-cultures, no. — The Determination of 
the Motility of Bacteria, in. — 3. The Inoculation of Animals, 112. — 
Guinea-pigs, 112. — Rabbits, 113. — Mice, 115. — The Care of Animals, 117. — 
4. Cultivation without Oxygen (Anaerobic Cultures) : Method of 
Liborius, 117; Method of Buchner, 119; Esmarch's Method, 119; Bouillon 
Cultures under Hydrogen, 119. 

V. BACTERIOLOGICAL DIAGNOSIS. 

Staphylococcus Pyogenes Aureus, 121. — Staphylococcus Pyogenes Albus and 
Citreus, 1 24. — Staphylococcus Epidermidis Albus, 124. — Staphylococcus Cereus 
Albus and Flavus, 124. — Streptococcus Pyogenes, 124. — Pneumococcus, 128. — 
Gonococcus, 130: Special Culture-media, 131 ; Serum Agar-agar, 131 ; Urine- 
Sei-um-Agar-agar, 132. — Micrococcus Tetragenus, 133. — Diplococcus Intracel- 
lularis Meningitidis, 135. — Bacillus Diphtherial, 137. — Bacillus of Typhoid 
Fever, 141 : Differential Diagnosis between the Bacillus of Typhoid Fever and 
the Bacillus Coli Communis, 143. — Bacillus Coli Communis, 145. — Bacillus 
Tuberculosis, 148. — Spirillum of Asiatic Cholera (Comma Bacillus), 152. — 
Bacillus of Anthrax, 156. — Bacillus Pyocyaneus (Bacillus of Green Pus), 160. 
— Bacillus of Influenza, 162. — Bacillus of Glanders (Bacillus Mallei), 164. — 
Bacillus Proteus (Proteus Vulgaris), 167. — Bacillus Mucosus Capsulatus, 168. — 
Bacillus of Tetanus, 171. — Bacillus Aerogenes Capsulatus, 173. — Bacillus of 
Malignant Edema, 175. — Actinomyces, 176. 



CONTENTS. 1 5 

VI. CLINICAL BACTERIOLOGY. 

General Considerations, 178; Cover-glass Examinations, 180; Preparation 
of Cultures, 180; Animal Inoculations, 181. — Suppurative Processes, 181. — 
Erysipelas, 181. — Peritonitis and Appendicitis, 181. — Pleural, Pericardial, and 
Joint Exudates, 182. — Anthrax, or Malignant Pustule, 182. — Diphtheria, 182: 
Special Methods of Staining the Bacillus Diphtheria?, 184. — Influenza, 185. — 
Examination of Sputum for Tubercle Bacilli, 186. — Tubercle Bacilli in Urine, 
188. — Surgical Tuberculosis, 189. — Cultures from the Blood during Life, 190. — 
Gonorrhea, 190: Method of Staining for Gonococci, 191. — Gonorrheal Con- 
junctivitis, 192. — Pyosalpinx, 192. — Cerebro-spinal Meningitis, 192. — Glan- 
ders, 193. — Tetanus, 193: Method of Isolation, 193. — Asiatic Cholera, 195. — 
Typhoid Fever, 198: Isolation of the Typhoid Bacillus from the Feces, 198; 
Capaldi's Culture-medium, 200; The Blood-serum Reaction in Typhoid Fever, 
201. — Rabies (Hydrophobia), 201. — Leprosy, 203. — Actinomycosis, 203. 



PART III. 

HISTOLOGICAL METHODS. 

Introduction, 204. — Laboratory Outfit : Microscopes, 204. — Freezing Micro- 
tome, 206. — Celloidin Microtome, 209. — Paraffin Microtome, 210. — Paraffin 
Bath, 2IO. — Vulcanized Fiber, 211. — Knives, 212. — Running Water, 213. — 
Slides, 213. — Cover-slips, 214. — Staining Dishes, 214. — Metal Instruments, 215. 
— Bottles, 216. — Examination of Fresh Material, 216. — Indifferent Fluids, 
217. — Macerating Fluids, 218. — Examination of Fluids, 218. — Injections, 
218. — Cold Injection-masses, 219. — Warm Injection-masses, 219. — Fixing Re- 
agents, 220. — -Alcohol, 222. — Zenker's Fluid, 223. — Orth's Fluid, 224. — 
Flemming's Solution, 224. — Hermann's Solution, 225. — Pianese's Solution, 
225. — Rabl's Chromo-formic Acid Solution, 225. — Corrosive Sublimate, 225. — 
Formaldehyde, 226. — Boiling, 227. — Miiller's Fluid, 227. — Marchi's Fluid, 228. 
— Erlicki's Fluid, 228. — Decalcification, 228. — Directions for Using Nitric 
Acid, 229. — Phloroglucin and Nitric Acid, 229. — Picric Acid, 230. — Trichlor- 
acetic Acid, 230. — Imbedding Processes, 230. — Celloidin, 231. — Imbedding 
in Celloidin, 231. — Imbedding in Paraffin, 234. — Serial Sections by the Celloidin 
Method, 237. — Serial Sections by the Paraffin Method, 239. — Staining Solu- 
tions : Hematoxylin and Hematein Stains, 239. — Carmine Stains, 244. — Aniline 
Dyes, 245. — Diffuse Stains, 249. — Combination Stains, 250. — Pianese's Staining 
Solutions and Staining Methods, 250. — Orcein, 253. — Iodin, 253. — Lugol's Solu- 
tion, 254. — Acid Alcohol, 254. — Aniline Water, 254. — Carbolic-acid Water, 255. 
— Mayer's Glycerin-albumin Mixture, 255. — Clearing Reagents, 255. — Mount- 
ing Reagents, 258. — Metallic Stains or Impregnations, 258. — Silver, 258. 
Gold, 260. — Osmic Acid, 261. — Staining Methods, 262. — Nuclear Stains, 
265. — Alum-hematoxylin Stains, 266. — Aqueous Alum-hematoxylin ; Delafield's 
Hematoxylin; Ehrlich's Acid Hematoxylin, 267. — Mayer's Hemalum, 268. — 
Hcidenhain's Hematoxylin Stain, 268. — Carmine Stains, 268. — Aniline Dyes as 



1 6 CONTENTS. 

Nuclear Stains, 269. — Diffuse or Contrast-stains, 271. — Combination Stains, 
272. — Staining in Mass, 273. — Mitosis, 273. — Directions for Staining Karyomi- 
totic Figures with Safranin, 274. — The Staining of Bacteria in Tissues, 
275. — Pathogenic Bacteria which do not Stain by Gram, 277. — Gonococcus, 
278. — Typhoid Bacillus, 278. — Influenza Bacillus, 279. — Glanders Bacillus, 
279. — Friedlander's Capsule-bacillus, 280. — Pathogenic Bacteria which Stain 
by Gram, 280. — Bacillus of Rhinoscleroma, 282. — Actinomyces, 282. — Bacteria 
that Stain by the Tubercle-bacillus Method, 283. — Tubercle Bacillus, 283. — 
Bacillus of Leprosy, 285. — Syphilis Bacillus, 286. — Smegma Bacillus, 286. — 
Methods of Examination of Animal Parasites, 287. — Protozoa, 287. — 
Malaria] Organisms, 287. — Ameba Coli, 292. — Sporozoa, 294. — Round-worms, 
294. — Trichinae, 295. — Tape-worms, 296. — Taenia Solium, 296. — Taenia Medio- 
canellata s. Saginata, 298. — Taenia Echinococcus, 298. — Bothriocephalus Latus, 
298. — Special Stains for Certain Tissue-elements other than Nuclei, 
298. — Mastzellen, 298. — Plasma-cells, 300. — Connective-tissue Fibrillae, 300. — 
Elastic Fibers, 301. — The Central Nervous System, 303; General Stains, 305 ; 
Stains for Ganglion-cells, 307; Stains for the Myelin-sheath, 316; Stains for 
the Neuroglia-fibers, 321. — Degenerations of the Nervous System, 325. — 
Examination of the Blood, 326.— Apparatus Used in the Examination of 
the Blood, 327. — Preparation of Apparatus, 330. — Obtaining the Blood, 331. — 
The Hemoglobin Test, 332. — Estimation of Number of Red Corpuscles, 333. — 
Cover-glass Preparations, 336. — The Elements of the Blood, 338. — Methods of 
Staining, 342. — Methods of Fixing and Examining Special Organs and 
Tissues, 344. — Acute Inflammatory Exudations; Granulation-tissue, 345. — 
Lung, Spleen, Bone-marrow, Kidney, 346. — Gastro-intestinal Tract, 347. — 
Liver, 347. — Bone and Cartilage, 348. — Museum Preparations, 350. — Patho- 
logical Products, 352. — Cloudy Swelling; Albuminous Degeneration, 352. — 
Fatty Degeneration, 352; Necrosis, 354. — Caseation, 355. — Demonstration of 
Fibrin, 355. — Mucin, 356. — Pseudo-mucin, 358. — Colloid and Hyaline, 358. — 
Glycogen Infiltration, 361. — Amyloid Infiltration, 362. — Pigmentation, 365. — 
Petrifaction, 368. — Clinical Pathology, 368. — Examination of Tissues from 
Clinical Cases for Diagnosis, 369. — Uterine Scrapings, 369. — Examination of 
Fluids obtained by Puncture, 370. — Lumbar Puncture, 371. — Ovarian and 
Parovarian Cysts, 374. — Pancreatic Cyst or Fistula, 374. — Dropsy of the Gall- 
bladder, 375. — Hydronephrosis and Renal Cysts, 375. — Echinococcus Cysts, 
375. — Examination of the Sputum, 376: Macroscopic Examination, 376; Micro- 
scopic Examination, 378. — Examination of the Gastric Contents, 380. — Exami- 
nation of the Feces, 382. — Examination of the Urine, 382. 



PATHOLOGICAL TECHNIQUE. 



PART I. 

POST-MORTEM EXAMINATIONS. 



Introduction. — The method of making post-mortem 
examinations as originally taught by Virchow has been 
variously modified in its details by his pupils and followers. 
We have endeavored, while following in general his plan, to 
select those modifications that have proved simplest and of 
greatest value. In certain instances we have not hesitated 
to adopt, or at least to call attention to, useful methods of 
procedure originating in the Rokitansky school of pathology, 
as now best exemplified by Chiari. 

The problem offered by an autopsy is often solved in part 
or wholly by the macroscopic post-mortem examination. 
More frequently, however, the complete and final solution 
is reached only after careful bacteriological and histological 
study. The post-mortem examination may, therefore, be 
looked upon as the beginning of the solution of the prob- 
lem. Its particular function is to demonstrate in the indi- 
vidual case all congenital or acquired abnormalities, all 
macroscopic lesions, and to explain all gross mechanical 
questions. It furnishes the material for bacteriological and 
histological study. Perfectly to accomplish its purpose a 
post-mortem examination must be made in a careful, sys- 
tematic manner. 

While a general method of procedure is advisable, it will 
often be found advantageous, or even necessary, to depart 
2 17 



1 8 PATHOLOGICAL TECHNIQUE. 

from it. According to Orth, " the chief requisite of every 
exact post-mortem examination is this, that no part shall be 
displaced from its position until its relations to the surround- 
ing parts are established, and that no part shall be taken out 
by whose removal the further examination of other parts is 
affected." 

The order and method of procedure in making a post- 
mortem examination, including the various incisions, may be 
said to have been planned for the routine examination of 
normal or diffusely diseased organs. As soon as a notice- 
able focal lesion is present the order of procedure and the 
customary method of removal and of incision must be so 
altered as best to display the lesion. 

Instruments. — The following instruments will be found 
extremely useful in the autopsy-room, although not all of 
them are necessary : 

The autopsy-table should be large, so as to accommodate 
on it the instruments and several dishes in addition to the 
body. It should have a slightly raised edge, and should 
slope gently toward an opening in the center for the escape 
of fluids. The table is best made of zinc, and along one 
edge should have a centimeter scale. The water for use on 
the table is best supplied by a rubber tube from an overhead 
pipe reaching to within 60 to 100 cm. of the table. 

The scales for weighing the various organs should have a 
large pan and gram and kilogram weights. 

A band-saw will be found very useful for sawing bones for 
the inspection of the marrow, and for calcified and osseous 
tumors. 

The best autopsy-knife is a stout, broad-bladed knife with 
bellied edge and heavy handle. The blade should measure 
about 12 cm. in length and 3 cm. in width ; the handle should 
be 12 cm. in length. Many operators prefer a somewhat 
smaller knife than this. 

Amputating-knives of different sizes are useful for long, 
deep cuts into organs and tumors. 

A myelotome is a short, thin, narrow knife-blade, 1.4 cm. 
long and 4 mm. wide, set obliquely on a slender steel stalk 



POST-MORTEM EXAMINATIONS. 



19 



ending in a wooden handle (Fig. 2). It is used only for 
cutting the cord squarely across in removing the brain. 




Fig. i.-Instruments for use in the autopsy-room: a, saw; b, holder for the 
head ; c, steel hammer with wedge end and blunt hook on the handle ; d, costo- 
tome ; e, bone-cutter ; /, hatchet-chisel ; gt autopsy-knife. 

Cartilage-knives and scalpels of different sizes are used for 
a variety of purposes. 

Scissors, both straight and curved, should be of various 



20 PATHOLOGICAL TECHNIQUE. 

sizes. A medium-sized and a fine pair should each have 
one probe-pointed blade. 

An enterotome is a long, straight pair of scissors, of which 




FIG. 2. — Myelotome. 



one blade is longer than the other and blunt at the extremity 
(Fig. 3). A hook at the end is not advisable. The instru- 
ment is used in opening the heart and the intestines. 




Fig. 3. — Enterotome. 



A saw with movable back and rounded end will be found 
the most generally useful for opening the skull and the 




Luer's double rachiotome. 



spinal canal. An ordinary meat-saw is preferred by some, 
but cannot be used on the vertebrae. 

Luer's double rachiotome, or adjustable double saw (Fig. 4), 
is very useful in removing the cord, and is the safest instru- 
ment to put into the hands of beginners. 



POST-MORTEM EXAMINATIONS. 21 

Forceps : several sizes, large and small, mouse-toothed. 

Costotome : heavy bone-shears for cutting the ribs. 

A powerful bone-cutter ; with short blades, 5 cm. long, set 
at an angle of about 45 ° to the handles, which are 36 cm. 
in length, is employed for dividing the arches of the cervical 
vertebrae and for other purposes where ordinary bone-cutters 
will not do. 

A chisel with 2 cm. cutting edge, for exposing the marrow 
of the long bones, removing portions of the base of the 
skull, etc. 

A hatchet-chisel of steel for starting the calvaria and spinous 
processes after sawing the skull and the vertebral column. 

Soft-iron hammer with wooden handle. 

Steel hammer with wedge end, and blunt hook on the 
handle. 

Holder for the head while sawing the skull. 

Autopsy-needles, long and a little curved. 

Prohes of flexible metal ; also fine glass probes for small 
blood-vessels or ducts. 

Grooved director. 

Pans for holding water, organs, etc. 

Boards, square or oblong, 30 X 30 or 30 X 50 cm., on 
which to lay instruments or cut organs. 

Sponges. 

Catheters. 

Strong hemp twine is the best for sewing up the body. 

Glass graduates for measuring fluids. 

A block of wood with shallow depression for the neck ; for 
use while opening the head. 

Vise. 

Small cup or dish for removing fluid from cavities. 

General Rules. — The room for an autopsy should be 
well lighted, otherwise the finer changes in the tissues cannot 
be recognized. Artificial illumination is not good, because 
the colors of the tissues are entirely changed by the yellow- 
ness of the light. 

Before beginning an autopsy the necessary instruments 



22 PATHOLOGICAL TECHNIQUE. 

should be arranged on a short board on the autopsy-table in 
the order in which they are most likely to be used. 

The operator stands on the right side of the body. This 
position he rarely leaves except for some definite purpose ; 
for example, in opening the skull he stands at the head. 

Order and cleanliness are the first points to be insisted 
upon at every autopsy. Clean water should always be at 
hand for washing the instruments and for keeping the hands 
free from blood and pus. The cut surface of an organ should 
not be washed with water except to remove blood ; gently 
scrape the surface with the knife held obliquely. 

In cutting, the knife should be drawn, not pressed or 
shoved into the tissues. According to Virchow, a broad, 
clean cut into an organ, even if incorrectly made, is much 
better than several short cuts which leave a ragged surface. 

The autopsy-knife should be grasped in the hand as if to 
cut bread. In using this knife the main movement should be 
from the shoulder, not from the wrist as in dissecting. It 
goes without saying that the sharper the knife the better. 

In cutting the brain and cord, especially if their consistency 
is lessened, moisten the knife to prevent the tissue from stick- 
ing and tearing. 

Before beginning an autopsy it is important to know the 
main points in the clinical history of the case, as they may 
greatly lighten the work of investigation by calling attention 
to those organs that require special examination. 

The record of an autopsy should be dictated by the ope- 
rator as he proceeds with the examination of the case, and 
should be as nearly as possible an objective description of 
the appearances found. Only the anatomical diagnosis 
should express the opinion of the operator. If it is not 
convenient to dictate the autopsy during its performance, 
the description of the lesions certainly ought to be made 
with the organs in sight, and not from memory after the 
lapse of hours or even days, when many of the details may 
be forgotten. Later, the results of the bacteriological and 
histological examinations should be added to the autopsy 
report, so as to make the case complete. 



POST-MORTEM EXAMINATIONS. 2$ 

Rubber gloves are sometimes worn to protect the hands 
while making a post-mortem examination ; but they greatly 
dull the sense of touch, and cannot be recommended for 
routine work except while opening the stomach and intes- 
tines. Rubber cots for the fingers are often useful. 

For cuts on the fingers use celloidin dissolved in equal 
parts of alcohol and ether, instead of flexible collodion, 
because the latter will not stick. A cut received during an 
autopsy should immediately be washed thoroughly, and then 
sucked so that the blood will flow freely. For protection 
during the rest of the autopsy use a rubber glove or cover 
the cut with celloidin. 

It is always well to wash the hands after an autopsy with 
an antiseptic solution, such as corrosive sublimate (i : 2000). 
For removing odors from the hands turpentine will often be 
found serviceable, or a saturated solution of permanganate 
of potassium followed by oxalic acid. Orth highly recom- 
mends a dilute solution of formaldehyde for this purpose. 

Suggestions to Beginners. — In a case of general 
miliary tuberculosis the older focus from which the organ- 
isms have spread must always be found. Look especially 
for tubercular thrombi in the pulmonary veins as the frequent 
source of the general infection. 

In a case of embolism hunt for the thrombus, bearing in 
mind, however, that the whole of a thrombus may become 
free and form an embolus. An arterial embolus may be due 
to a venous thrombus, in which case it must have passed 
through an open foramen ovale, except in the case of 
thrombi of the pulmonary veins. 

In acute peritonitis always seek for a source of infection 
(appendix, female genitals, gastro-intestinal tract, etc.). It 
cannot always be found. 

In hemorrhage from the stomach associated with cirrhosis 
of the liver look for rupture of dilated esophageal veins. 

In cases of more or less sudden death, especially if pre- 
ceded by signs of asphyxia, always examine the pulmonary 
artery in situ for possible emboli. In cases of instantaneous 
death examine the coronary arteries. 



24 PATHOLOGICAL TECHNIQUE. 

Private autopsies must often be made under many dis- 
advantages, and, when out of town, not infrequently in a 
short space of time. It is always important to warn the 
attending physician not to allow the undertaker to inject the 
body before the autopsy, because the color and consistency 
of the organs are so changed by most injecting fluids that it 
is difficult to recognize the pathological processes. If there 
is danger of post-mortem changes, have the body packed 
in ice. 

A regular autopsy-bag will be found very convenient for 
carrying to private autopsies. It is made of black leather 
lined with rubber, and measures about 40 X 1 8 X 20 cm. Loose 
within it is carried a rubber bag 40 X 24 X 20 cm., shaped 
like a short envelope with a flap (22 cm. long) on one side, 
for bringing away any organs that demand further examina- 
tion. The case of instruments should contain one or two 
autopsy-knives, two scalpels, a pair of forceps, one or two 
pairs of scissors, an enterotome, a steel hammer with wedge- 
end and with a blunt hook on the handle, a small chisel, a 
saw with detachable handle and back, an autopsy-needle, 
and a probe ; free within the bag should be carried a spool 
of strong twine, a costotome, a long slender knife for use in 
removing the brain, a hammer with soft iron head, and a 
sponge. In rare cases additional instruments may be re- 
quired. A white duck apron for personal use will always 
be found convenient. It is also well to carry along several 
blood-serum tubes and a platinum needle for making cultures 
at the autopsy. When there is a lesion of the nervous sys- 
tem it is advisable to bring a jar of a 4 per cent, solution of 
formaldehyde and to place the tissue in the fluid at the 
autopsy, as otherwise it is not easily gotten to the laboratory 
in good condition. 

At the house can always be obtained a slop-pail, a wash- 
bowl, a pitcher of water, several newspapers, and an old 
sheet. The body is usually on an undertaker's frame, but 
it may be in an ice-box or on the bed. The examination of 
the chest and abdomen can be made in any of these posi- 
tions. If, however, the body is in an ice-box, it must be 



POST-MORTEM EXAMINATIONS. 25 

raised to the level of the top of the box in case it is neces- 
sary to open the head. 

The clothing on the body can be removed, or, if only a 
shirt or a night-dress, is best slit down the middle and turned 
out over the arms. Tear the sheet into four equal pieces. 
Fold and tuck in one piece on each side of the trunk and 
neck, allowing the outer portion to fall over the arms. Fold 
and lay the third piece on the lower extremities, tucking the 
upper end beneath the clothing below the pubes. The 
fourth piece can be placed beneath the head if it is to be 
opened. This procedure leaves the front of the thorax and 
abdomen free for operation and protects the rest of the body 
and the clothing. On the thighs place one or two folded 
newspapers, and on these the necessary instruments. On the 
legs place the bowl containing only a dampened sponge. 
If the undertaker has not put a rubber sheet on the floor 
beneath the body and on the side where the operator is to 
stand, newspapers should be spread to protect the carpet. 
Place the slop-pail on the rubber sheet within convenient 
reach. Having thus made all arrangements, even to the 
threading of his needle, the operator is ready to begin. 

If the cord and brain have to be examined as well as the 
body, it is best to do the cord first, so as to avoid the leak- 
age that might otherwise occur from the trunk-cavities if 
they had been opened first. To support the head while 
opening it, use a stick of wood, a brick, or, in case of neces- 
sity, the instrument-box wrapped in a newspaper. 

At a private autopsy cleanliness is extremely important. 
If there is no undertaker or nurse present, the operator 
himself must see that everything is cleaned and put in order 
before leaving, that all the blood-stains are removed from the 
dishes, and that all papers and soiled cloths are burned or 
rolled up and left in a neat bundle for the undertaker to dis- 
pose of. Ground coffee thrown on a shovelful of burning 
coals will be found an excellent deodorizer for the room 
after the autopsy. 



26 PATHOLOGICAL TECHNIQUE. 

EXTERNAL EXAMINATION OF THE BODY. 

External examination is often of great importance, espe- 
cially in medico-legal autopsies, and should never be ne- 
glected, as it may throw great light on lesions found within 
the body. It should be systematic and careful, and is best 
taken up in the following order : 

I. Inspection of the Body as a Whole. 

1. Sex. 

2. Age. 

3. The body-length should be measured on the table beside 
the body, between points opposite the vertex of the head 
and the sole of the foot beneath the ankle. 

4. The development of the skeleton has reference to the 
bony framework, which may be powerful, slender, or de- 
formed. 

5. The general nutrition is shown by the amount of mus- 
cular development and of subcutaneous fat-tissue. The 
latter is judged by pinching up a fold of skin. 

6. The general condition of the skin includes amount of 
elasticity, bronzing, jaundice, edema, and decubitus. 

7. Post-mortem discolorations may be divided into three 
varieties : 

(a) Hypostasis of blood, or the settling of blood into the 
lowest lying blood-vessels ; this form of discoloration dis- 
appears on pressure. 

(b) Diffusion of blood-coloring matter out of the vessels into 
the surrounding tissues (due to blood-pigment being set free 
by post-mortem decomposition) ; does not disappear on 
pressure. 

(c) The greenish discoloration, usually seen earliest over 
the abdomen, is due to sulphate of iron formed through 
decomposition of the tissues. This discoloration is import- 
ant, as it may modify the interpretation of appearances 
observed in the internal organs. 

8. Post-mortem rigidity, degree and extent. It begins in 
the maxillary muscles, and spreads gradually from above 
downward, disappearing later in the same order. It is most 
marked and lasts longest in muscular individuals who have 



POST-MORTEM EXAMINATIONS. 2J 

been ill but a short time. Cholera furnishes the most marked 
cases. The rigor disappears quickest in cachectic diseases. 
When once it has been forcibly overcome, it does not recur. 
The time of beginning after death varies widely — from ten 
minutes to seven hours. 

II. Special Inspection of the Different Parts of the 
Body. 

The examination should begin with the head. Any lesion 
or abnormality found should be carefully noted. Particular 
attention should be paid to the condition of the pupils and to 
the color of the sclera. Then follow in order the neck, the 
thorax (size and shape), the abdomen (distended or retracted), 
the genitals, and the extremities. 

INTERNAL EXAMINATION OF THE BODY. 

The opening of the body-cavities is described first, be- 
cause the brain is relatively much less frequently the seat of 
disease, and because in this country it is often impossible to 
obtain permission to open the head. Moreover, the lesions 
in the body often throw much light on those to be expected 
in the brain. The advantage of examining the brain first, 
particularly in those cases in which the important lesions 
are cerebral, is said to be that the amount of blood in the 
cerebral vessels can be more accurately determined. After 
the heart has been removed some of the blood in the brain 
may escape through the severed vessels below. 

In routine examinations, however, the body is usually 
examined first, then the brain, and finally the cord. It is 
not a bad practice to remove the calvaria, to examine the 
meninges over the upper surface of the cerebrum, and then 
to make the examination of the body before removing the 
brain. In this way any change in the blood-supply of the 
cerebral vessels would be observed. 

Opening of the Abdominal Cavity. — In the exam- 
ination of the body the peritoneal cavity is opened first, the 
two pleural cavities next, and the pericardial cavity last. The 
cavities and their contents are to be inspected in the order 
and at the time that each is opened, but the organs are to 



28 



PA TBOL O GICAL TE CHNIQ UE. 



be removed from the cavities for further examination in the 
reverse order, beginning with the heart. 

The primary or long anterior incision to bare the thorax and 
to open the abdomen (Fig. 5) should extend from the larynx 
to the pubes, passing to the left of the umbilicus, so as not 
to cut the round ligament. In cutting, the handle of the 
knife is depressed so as to use the belly of the blade rather 




Fig. 5. — Primary incision in the body (Nauwerck). 



than the point. An incision beginning as high as the chin 
is, unfortunately, rarely allowable. Over the sternum the 
cut should extend down to the bone ; over the abdomen, 
however, only into the muscles, or in fat people through the 
muscles into the subperitoneal fat-tissue. To open the ab- 
dominal cavity, nick carefully through the peritoneum just 
below the sternum, introduce the first and second fingers of 



POST-MORTEM EXAMINATIONS. 29 

the left hand, and while making strong upward and outward 
traction on the right abdominal flap extend the incision to 
the pubes. Some operators prefer to separate the fingers 
and to cut between them. 

The abdominal flaps are rendered much less tense by cut- 
ting the pyramidales and recti muscles from below just above 
the pubis. Care must be taken not to injure the overlying 
skin. The abdominal cavity can now be examined, but 
more room will be obtained if the skin and the underlying 
muscles be first stripped back from the thorax to about 5 
cm. outside of the costochondral line. 

The operation is most easily and neatly done by lifting the 
skin directly away from the chest-wall or turning it forcibly 
out with the left hand, and then cutting the tense tissue close 
to the cartilages and ribs with long sweeps of the knife held 
almost flat. The operation begins over the lower border of 
the ribs and extends upward. In dissecting off the skin and 
muscles from the left side the right hand works underneath 
the left. The mammae can easily be incised from the under 
side of the flap, and if necessary the axillary glands can be 
reached by dissecting the skin farther out, especially over 
the clavicle. Before beginning the inspection of the peri- 
toneal cavity it is important to examine first the surface of 
the incision into the abdomen, noting the thickness and color 
of the fat-tissue and the condition of the muscles. 

Inspection of the Abdominal Cavity. — The character 
of any fluid present should be determined and its amount 
measured or estimated. The simplest way to remove it is to 
dip it up with a small cup or dish and pour it into a glass 
graduate for inspection and measurement. If the presence 
of gas within the peritoneal cavity is suspected, a small 
pouch should be formed in the first incision as soon as it has 
been made and water poured in. The first opening into the 
abdominal cavity should then be made with the point of a 
scalpel at the bottom of the water, through which the gas, 
if present, will escape in bubbles. 

The various abdominal organs and their relations to each 
other are to be investigated in situ by sight and by touch. 



30 PATHOLOGICAL TECHNIQUE. 

As a rule, examine first the gastro-intestinal tract, including 
the appendix and the mesenteric lymph-glands. Ulcerations 
of the intestine can often readily be made out through the 
walls. The examination of the spleen, liver, kidneys, and 
pelvic organs follows. The pancreas is easily reached by 
tearing through the omentum between the stomach and the 
colon, so as to open the lesser peritoneal cavity. 

After the inspection of the abdominal organs the position 
of the diaphragm is to be ascertained on both sides in the 
costochondral line by measuring with the right hand passed 
palm upward underneath the ribs, and the left hand outside 
at the corresponding height to mark the position of ribs or 
intercostal spaces. On the right side the hand is to be 
passed up on the outside of the falciform ligament. Nor- 
mally, the diaphragm stands at the fifth rib on the left side, 
and at the fourth rib or fourth interspace on the right. 

Opening of the Thorax. — To open the thorax, cut 
through the cartilages close to the ribs from the second 
down (about 5 mm. distant) with a scalpel held nearly hori- 
zontal, so that as one cartilage is cut through the handle of 
the scalpel will strike the next below and prevent the blade 
from penetrating too far and injuring the lung. In young 
people the cartilages can be cut easily by one long stroke on 
each side, but care must be taken not to go too deep. If 
the intercostal muscles are not divided by the same opera- 
tion, the sternum can be depressed by the left hand and the 
muscles severed by one pass of the knife on each side. The 
lower end of the sternum can now be elevated and freed 
from below upward from the diaphragm and pericardium 
until the first rib is reached. The cartilage of this rib is to 
be cut about 1 cm. farther out than the others, and from 
below upward toward the clavicle, with the handle of the 
knife beneath the elevated sternum and with the point and 
edge of the knife directed upward and a little outward. The 
sternum is then to be still further freed from the anterior 
mediastinal tissue until its upper end is reached. The sterno- 
clavicular joint on the left side can now be easily opened 
from below by entering a scalpel just above the cartilage of 



POST-MORTEM EXAMINATIONS. 3 I 

the first rib, and following the irregular line of the joint 
around the end of the clavicle, while at the same time draw- 
ing the sternum over to the right side of the body. The 
right sterno-clavicular articulation is to be opened by con- 
tinuing the incision of the scalpel over the upper end of the 
sternum and into the second joint. The advantage of this 
method is that there is much less danger of wounding the large 
vessels at the base of the neck, and thus of mingling blood 
with any exudation which may happen to be present in the 
pleural cavities. If preferred, however, the articulations can 
be opened and the cartilages of the first ribs cut from above 
before freeing the sternum from the diaphragm. In this case 
enter a short, sharp, narrow-bladed scalpel held vertically, 
but loosely, into the left joint on its upper side, starting the 
incision just outside of the attachment of the sternal end of 
the sterno-mastoid muscle, and cut around the end of the 
clavicle by a series of short up-and-down strokes, allowing 
the blade to follow the irregular line of the joint. After cut- 
ting through the joint continue the incision outward and cut 
through the cartilage of the first rib. 

If the cartilages are calcified, use the costotome and cut 
through the ribs, as more room can be gained in this way, 
and they are more easily cut than calcified cartilages. When 
for any reason it is not permitted to open the thorax, the 
organs within it can be obtained through the opening into 
the abdominal cavity by freeing the diaphragm from the ribs, 
and removing first the heart and then the lungs. The 
sternum should be inspected at the time of its removal. It 
is perhaps best to examine next, especially in children, the 
epiphyses of the ribs at the costochondral line for any evi- 
dence of thickening. 

Inspection of the Pleural Cavities. — In the pleural 
cavities, as in the peritoneal cavity, the character and amount 
of any abnormal contents must be determined. If, from the 
clinical history or from any other reason, the presence of 
air in a pleural cavity is suspected, a pouch should be formed 
over the ribs by aid of the skin-flap and filled with water. 
The pleural cavity is then to be pierced with a scalpel 



12 PATHOLOGICAL TECHNIQUE. 

through the bottom of the pouch. Air, if present, will 
bubble up through the water. 

Slight adhesions are best torn through or cut. If the 
lungs are firmly attached, it is best to strip off the costal 
layer of the pleura with the lung. This is most easily done 
by starting the anterior edge of the costal pleura with the 
handle of the scalpel, and working in first a finger and then 
the whole hand until the pleura is entirely free. In passing 
the hand into the pleural cavities protect the back of it, 
especially if the ribs have been cut through, by folding the 
skin-flap in over the edge of the ribs. 

If desired, the lungs can be drawn forward, examined over 
their whole extent, even incised, and then replaced until the 
heart has been removed. In the connective tissue of the 
anterior mediastinum there is almost always a certain amount 
of emphysema due to the removal of the sternum. Emphys- 
ema due to laceration of lung-tissue is more marked in the 
upper half of the mediastinum, and usually extends up into 
the neck. The thymus gland attains its full development at 
the end of the second year, after which time it usually 
gradually disappears. 

Opening of the Pericardium. — To open the pericar- 
dium, seize the sac near the middle with fingers or forceps, 
snip through the wall with knife or scissors, and with either 
instrument cut upward to where the pericardium is reflected 
over the large vessels, downward to the lower right border, 
and lastly to the apex. By gently raising the apex of the 
heart the amount of fluid in the pericardial cavity can be 
seen. The normal amount is about a teaspoonful, but it may 
be increased to ioo c.c. in cases where the death-agony is 
prolonged. Pericardial adhesions should be broken through 
with the fingers. If this is impossible, the heart must be 
incised through the pericardium. 

External Inspection of the Heart. — Determine first 
the position, size, and shape of the heart, and the degree of 
distention of the different parts. The right ventricle and 
both auricles are usually distended with blood, which may 
be fluid as in death from suffocation or more or less coagu- 



POST-MORTEM EXAMINATIONS. 33 

lated. The left ventricle is contracted and empty unless the 
individual has died from paralysis of this part of the heart, 
when it will be found distended with blood (condition of 
greatest diastole). 

Opening of the Heart. — The heart may be opened in 
situ or after removal from the body. Except in certain cases, 
to be spoken of later, it usually will be found advisable to 
remove the heart before making any incision into it, for the 
reason that it can be more perfectly opened after removal, 
especially by beginners, and the danger of contaminating 
any bacterial lesions of the valves is lessened. 

To remove the heart, grasp it gently near the apex with 
the left hand, supporting it further, if necessary, by one or 
two fingers placed above the coronal suture, and lift the 
whole heart vertically upward. Then cut its vessels from 
below upward with the knife held transverse and oblique. 
Divide in turn the inferior vena cava, the pulmonary veins on 
both sides, the superior vena cava, the pulmonary artery, 
and the aorta. Go deep enough to remove the auricles 
entire, but avoid injury to the underlying esophagus. 

For making the incisions to open the heart either a long, 
slender-bladed knife or long, straight scissors may be used. 
The heart should be placed on a board with its anterior sur- 
face up. The right auricle is opened by cutting from the 
orifice of the inferior vena cava into that of the superior, 
and from the latter into the auricular appendage. The first 
incision to open the right ventricle is made through the tri- 
cuspid valve and the wall of the ventricle along the under 
surface of the right border of the heart. It should be 
carried to the end of the ventricle, which does not reach 
quite to the apex of the heart. The second incision begins 
about the middle of the first, just above the insertion of the 
anterior papillary muscle (which should not be cut), and is 
carried through the pulmonary valve well over on the left 
side along the left border of a narrow, projecting ridge of 
fat-tissue usually present, so as to pass between the left ante- 
rior and the posterior segments of the valve. 

The left auricle is opened in a manner similar to the right 
3 



34 



PA THOL O GICA L TE CHNIQ UE. 



by incisions joining the four orifices of the pulmonary veins 
and extending into the auricular appendage. 

The first incision into the left ventricle is through the 
mitral valve along the left border of the heart [i. e. the 
middle of the external wall of the left ventricle), between 
the two bundles of papillary muscles, to the apex of the 
heart. The second incision begins at the termination of the 
first at the apex, and is carried up close to the interven- 
tricular septum, parallel to the descending branch of the 



iO 





// 



Fig. 6. — Heart, showing incisions. 



anterior coronary artery and about I cm. from it. The 
upper portion of the incision should pass midway between 
the pulmonary valve and the left auricular appendage. 
Ordinarily, one of the aortic cusps is divided, but this may 
be avoided, if desired, by dissecting away to some extent the 
pulmonary artery from the aorta and carrying the incision 
well over to the right between the right posterior and ante- 
rior valve-segments. As each auricle is opened the blood 
and clots it contains should be carefully removed and the 
auriculo-ventricular valves carefully inspected from above. 
In certain cases — as, for instance, extreme stenosis — it may 
be preferable not to cut through the valve, but to begin the 



POST-MORTEM EXAMINATIONS. 35 

incision in the ventricular wall below the valve. The ven- 
tricular cavities should in like manner be freed from clots 
and the valves closely inspected. The coronary arteries 
should always be opened by means of small, narrow-bladed, 
probe-pointed scissors as far as they can be followed. The 
examination of the descending branch of the anterior artery 
is especially important. The posterior coronary is best 
opened by placing the tip of the left fore finger in the aorta 
over the orifice of the artery, and cutting from without in 
toward the finger-tip until the vessel is reached, when it can 
easily be slit up. In this way injury to the aorta is avoided. 

In cases of more or less sudden death with symptoms of 
asphyxia the pulmonary artery should always be opened in 
situ before removal of the heart, in order to examine for pos- 
sible emboli, because they often lodge just at the point where 
the vessels are severed in removing the heart and lungs, and 
easily may slip out unobserved. The simplest operation is 
to thrust a sharp-pointed scalpel through the artery just 
above the valve on the left side in the line of incision already 
described, and to cut upward until the branches to the right 
and left lungs are reached. If desired, this incision may be 
extended down through the pulmonary valve and the ven- 
tricular wall along the line given for the second incision in 
the right ventricle. 

The water-test for the competence of the valves of the 
heart is not very reliable, especially for the auriculo-ven- 
tricular valves, and is not so much used as formerly. 
Inspection and measurement of the valve after the heart 
has been opened will usually enable one to judge fairly 
accurately concerning the degree of competence. Before 
applying the test to the aortic valve the first incision into 
the left ventricle must be made and the cavity freed from 
clots, so that no obstruction will exist below the valve. 
Then the heart is to be held so that the aortic valve is per- 
fectly horizontal, and water poured in from above to float the 
cusps out. If competent, they should keep the water from 
flowing through. If, however, in holding the heart the nor- 
mal relations of the valve and the surrounding parts are not 



36 PATHOLOGICAL TECHNIQUE. 

maintained, the valve may leak. A second source of error 
is that the water may escape through the coronary arteries, 
branches of which have been cut in opening the ventricle. 
In testing the mitral valve the left auricle is first opened and 
the clots removed, so as to expose the upper surface of the 
valve. Then the nozzle of a syringe is introduced through 
the aortic valve and water forced in so as to float the mitral 
curtains up. The test, however, is very unreliable, because 
the parts cannot be placed under natural conditions. 

The pulmonary and tricuspid valves can, of course, be 
tested by methods similar to those already described. 

Increase or diminution in the size of the heart is best 
determined by weighing the organ after the removal of the 
clots. In certain cases, however, and in special investigations 
measurements of different parts of the heart are desirable. 
Roughly, the heart is the size of the individual's fist. 

The following weights and measurements are taken from 
Nauwerck 's Sectionstechnik : 

Weight of the heart averages in men, 300 gr. ) ^ ,, 

" " " " women, 250 " J 

Krause gives the average weight of the heart as 292 gr. 
Relative weight of heart to body in men, 1-169 ) ^ 

" " " " women, 1-162 / 

Length of heart in men, 8.5-9 cm - \ /?• / 

" " women, 8.0-8.5 " i 

Circumference of heart at base of ventricles, 28.8 cm. (Sappey). 
Thickness of wall of left ventricle, 1.1-1.4 cm. ) ^ 

" " right " 0.5-0.7 " J 

Thickness of wall of left ventricle (without trabecule), 7-10 mm. \ ~ , 

« " right " " " 2-3 " J 

Circumference of mitral orifice, 10.4 (W.), 10.9 (M.) ] 
" " tricuspid " 12.0 (-W.), 12.7 (M.) | 

" aortic " 7.7 (W.), 8.0 (M.) f 

" " pulmonary orifice, 8.9 (W.), 9.2 (M.) J 

" " ascending aorta, 7.4 cm. 

" " pulmonary artery, 8.0 cm. (Buhl). 

The directions given for the removal and opening of the 
heart apply only when the organ is normal or contains 
lesions within itself which are not in continuity with any of 
the vessels entering into it. In aneurysm of the ascending 



POST-MORTEM EXAMINATIONS. 7)7 

aorta, in thrombosis of a vena cava, and in a number of dif- 
ferent lesions connected with the heart or with the vessels 
given off from it, it is important to examine these vessels 
and to open them while they are still in continuity with the 
heart. For this purpose it is often necessary or advantageous 
to remove the thoracic organs in one piece, so as to be able 
to examine the central circulatory apparatus in continuity 
from the front and back before disturbing any of its relations. 
This is done by cutting across the trachea and adjoining 
tissues as high in the neck as necessary or possible, and dis- 
secting them free from the cervical vertebrae and the first 
ribs. Then by drawing the trachea and surrounding tissues 
forcibly forward the aorta and overlying organs can be easily 
stripped from the vertebral column as low as the diaphragm. 
The left hand is now placed around the lower end of the 
pericardial sac, the aorta, and the esophagus just above the 
diaphragm, and the vessels are severed by cutting between 
the hand and the diaphragm. 

More space for the examination in situ of the vessels at 
the base of the neck can be obtained by freeing the clavicles 
from all attachments above and to the first ribs and drawing 
them forcibly outward ; this operation will be found especially 
useful in following up the subclavian vessels. 

Removal of the IyUngS. — Pleural adhesions have al- 
ready been spoken of. If the base of the lung is adherent 
to the diaphragm, it is usually advisable to remove the latter 
with the lung by cutting through its insertion into the ribs. 
According to Orth, there is less danger of wounding the ab- 
dominal organs if scissors be used for the performance of 
the operation. After the lung is free it is drawn forward 
out of the pleural cavity, and the root of it is grasped from 
above downward between the separated fingers (first and 
second or second and third) of the left hand. The lung, 
thus resting in the palm of the left hand, is first drawn 
downward toward the pubes until the primary bronchus is 
divided by a nearly vertical incision above and behind the 
left hand. Then the lung is lifted vertically upward, and the 
rest of its attachments cut in the same direction from above 



38 PATHOLOGICAL TECHNIQUE. 

downward by the knife held transverse and flat, so as to 
avoid injuring the esophagus and aorta. 

The procedure is the same for both lungs. "Once in a 
great while the apex of a lung will be found so firmly adhe- 
rent by dense scar-tissue that it can be freed only by using 
the knife. 

The primary or main incision into a lung is a long, deep 




Fig. 7. — Method of incising the lung (Nauwerck). 

cut from the apex to the base and from the convex surface 
to the root, slitting the primary bronchus, and thus not cut- 
ting it off from its branches to the upper and lower lobes 
(Fig. 7). To incise the left lung, place it with its inner or 
median surface and root downward on a board and with its 
base toward the operator. The left thumb steadies the lower 
lobe ; the first finger reaches between the two lobes almost 
to the primary bronchus ; and the rest of the fingers should 
hold the upper lobe. 



POST-MORTEM EXAMINATIONS. 39 

The right lung is most easily incised by placing it in the 
same position, but with the apex toward the operator ; in 
other words, always place the anterior edge of a lung beneath 
the palm of the hand. Some prefer to place each lung on 
its lower or diaphragmatic surface for incision. The right 
middle lobe is incised separately by a cut extending trans- 
versely in its greatest diameter. 

The bronchi and blood-vessels should be opened up for 
some distance with small probe-pointed scissors — as a rule 
from the surface of the section — cutting through the over- 
lying lung-tissue. In some cases, however, it is best to open 
up both the blood-vessels and the bronchi from the outside 
of the lung before incising it. The order to follow is vein 
first, then artery, and finally the bronchus. 

Secondary cuts into the lung are to be made parallel to 
the main incision. 

The bronchial lymph-glands should be incised from the 
outside of the lung. 

Organs of the Neck. — The operation of the removal 
of the organs of the neck is greatly facilitated if it is pos- 
sible to continue the primary skin-incision up to the chin. 
In other cases dissect the skin from the larynx and muscles 
of the neck as far up as possible. In like manner free the 
muscles, esophagus, and trachea from their attachments later- 
ally and posteriorly. Then allow the head to drop well back 
over the end of the table, and pass a long, slender-bladed 
knife up between the skin and the larynx, just behind the 
symphysis of the lower jaw, until the point of the knife 
appears beneath the tip of the tongue. From this point the 
knife is carried with a sawing motion down first one ramus 
of the jaw and then the other, dividing laterally the glossal 
muscles as far back as the posterior pharynx. The knife is 
next carried up behind the esophagus, and the posterior wall 
of the pharynx divided as high as possible. Pass the left 
hand up inside of the neck and draw down the tongue. 
Then cut the attachments of the soft to the hard palate, 
carrying the knife well out so as not to injure the tonsils. 
Any remaining attachments are usually easily severed by 



40 PATHOLOGICAL TECHNIQUE. 

pressing the tongue first to one side and then to the other, 
and cutting close to the roof of the pharynx. 

Each lobe of the thyroid gland is to be incised in its 
greatest diameter. 

Next cut through the middle of the uvula and examine 
all of the pharynx removed. Incise the tonsils vertically. 
The esophagus is to be slit in the median line posteriorly, 
and the larynx and trachea anteriorly. 

The Abdominal Cavity. — The order of removal of 
the abdominal organs varies with different operators, and 
under varying circumstances with the same operator. The 
gastro-intestinal tract, including the liver and pancreas, may 
be removed before or after the genito-urinary tract. The 
spleen as an organ by itself is often the first to be removed. 
The early removal of the liver is occasionally advantageous 
for the sake of the additional space obtained for the exami- 
nation of the other organs. It is well to practise the different 
methods of procedure, so that in a difficult case the best 
may be selected, because the examination of the abdominal 
cavity, especially in cases of extensive disease with numer- 
ous adhesions, is often one of the hardest tasks in post- 
mortem technique. As a rule, it is best to follow the usual 
order as long as possible, gradually removing the more or 
less normal or uninvolved organs. Occasionally it may be 
advisable to remove the organs en bloc, so as to be able to 
approach the problem from all sides. 

In all cases of acute peritonitis it is best before removing 
any organ to search for the source of the infection, paying 
particular attention to the vermiform appendix, to the gastro- 
intestinal tract, and, in females, to the pelvic organs. 

The order of removal of the abdominal organs adopted 
in this book for the majority of cases is that which seems 
the simplest and most natural — namely, to remove first the 
spleen as an organ essentially by itself; secondly, the gastro- 
intestinal tract, including the pancreas and liver, which forms 
the upper layer ; thirdly, the genito-urinary tract or middle 
layer, leaving the circulatory tract, the lowest layer, to be 
opened and inspected in situ. If, however, it proves neces- 



POST-MORTEM EXAMINATIONS. 4 1 

sary to open a part of the gastro-intestinal tract in situ, it 
will be neater perhaps to remove the kidneys and spleen 
first. Occasionally at private autopsies it may be unneces- 
sary to examine the intestinal tract ; under these circum- 
stances it is important to be able to get at the different 
organs without taking out the intestines. 

The Spleen. — As a rule, the spleen can easily be drawn 
forward from its bed behind the fundus of the stomach, be- 
neath the diaphragm, and lifted on to the lower edge of the 
ribs on the left side without cutting its vessels. The organ 
is then to be incised in its greatest diameter while thus firmly 
fixed between the left hand and the ribs ; or the vessels may 
be cut close to the hilus and the spleen incised after being 
placed on a board. 

In cases of adhesion to the diaphragm the spleen must be 
handled carefully while the fibrous attachments are torn or 
cut through, for the capsule is easily ruptured. Occasion- 
ally it is advisable to cut out with the spleen the portion of 
diaphragm attached to it. 

The important anatomical structures to be noted in the 
macroscopic examination are the capsule, trabecular, blood- 
vessels, follicles, and pulp. The weight of the spleen, ac- 
cording to Orth, varies from 150 to 250 grams. The aver- 
age weight is put at 171 grams. The spleen measures 12 X 
7.5 X 3 cm. 

The Gastro-intestinal Tract. — The first step is to 
examine externally, more or less carefully according to the 
clinical symptoms, the whole tract from the stomach to the 
rectum, if it has not already been done at the primary in- 
spection of the peritoneal cavity. The main points to notice 
are distention or contraction of the intestines, injection of the 
blood-vessels, thickening of the wall, especially in the lower 
part of the ileum, adhesions, exudations, etc. Inspect the 
mesentery, its length, the amount of fat, and the size of the 
lymph-glands ; incise the latter to determine color and con- 
sistency. Examine the mesenteric vessels if any evidence 
of infarction of the intestine is noticed. The portal vein and 
its branches should be opened up in situ, in all cases of ab- 



42 PATHOLOGICAL TECHNIQUE. 

scess of the liver or of secondary deposits in it of malignant 
growths, before the gastro-intestinal tract is removed. As a 
rule, it is not necessary to open any part of the gastro-intes- 
tinal tract in situ. The operation can be performed much 
more neatly at the sink. The duodenum is often opened for 
the sake of investigating the flow of bile from the gall-duct, 
but except in cases of jaundice the operation must be looked 
upon largely as a physiological experiment. 

Free the omentum from the transverse colon by putting it 
on the stretch and dividing it with the knife close to the 
colon. Then begin the removal of the large intestine by 
drawing the sigmoid flexure forcibly forward and cutting the 
mesocolon close to the gut, first down to the rectum, then 
upward to the transverse colon. Free the latter by dividing 
the two folds of the lesser omentum, if not already cut 
through, which unite it to the stomach. The ascending 
colon is to be freed in the same manner as the descending 
portion. Care should be taken not to injure the appendix. 
If the lower part of the sigmoid flexure be now stripped up- 
ward a short distance with the fingers, so as to force -the in- 
testinal contents out of the way, the gut can be divided just 
above the rectum without fear of the feces escaping. 

Place the freed intestine in a pan or pail, and as the small 
intestine is divided from its mesentery deposit it in the same 
receptacle. To remove the small intestine, begin at the ce- 
cum, and, while lifting the ileum with the left hand strongly 
enough to keep the mesentery constantly tense, cut the latter 
close to the intestine by playing the knife easily backward 
and forward across it with a fiddle-bow movement. Con- 
tinue the operation until the duodenum is reached. The 
mesentery can now be dissected from the duodenum and re- 
moved, or the mesentery, duodenum, pancreas, and stomach 
can be removed in continuity with the intestine by carefully 
dissecting them off the underlying structures. The opera- 
tion is perhaps more easily accomplished by freeing the 
organs from below upward. First cut down through the 
diaphragm and free it around the esophagus. Then separate 
the stomach from the liver by means of the thumb and fingers 



POST-MORTEM EXAMINATIONS. 43 

of the left hand in such a way as to put on the stretch the 
vessels of the hepato-duodenal ligament. These vessels 
(hepatic artery, common gall-duct, and portal vein) are then 
carefully divided in the order named. As each vessel is cut 
the character of its contents should be observed to see if 
anything abnormal is present.. 

The mesentery, if still present, the duodenum, the pan- 
creas, and the stomach, are now to be dissected carefully 
away from the underlying vessels from below upward until 
the esophagus is reached. This may be constricted by the 
fingers at any point desired, and cut across without danger 
of the gastric contents escaping and without the necessity 
of tying. In certain cases of hemorrhage from the stomach 
associated with cirrhosis of the liver it is important to re- 
move the esophagus in continuity with the stomach, because 
in these cases the hemorrhage usually takes place from 
dilated esophageal veins. 

The stomach and intestines are now to be opened at the 
sink by means of the enterotome, the colon along one of its 
longitudinal muscular bands, the small intestine along its 
mesenteric attachment, because the most important lesions 
usually occur opposite this line in the follicles and Peyer's 
patches. The stomach is opened by many along the greater 
curvature ; others, however, prefer to cut along a line 3 cm. 
from the lesser curvature, on the ground that better museum 
preparations are thus obtained. In case any tumor or focal 
lesion is perceived from the outside, it is advisable to cut the 
stomach, if possible, in such a way as to leave the patho- 
logical part uninjured. 

Whenever jaundice is present the duodenum must be 
opened in situ in order to examine the bile apparatus in con- 
tinuity, so as to determine whether the coloring is due to 
obstruction of the hepatic or common gall- ducts, or is of so- 
called hematogenous origin. 

To open the duodenum make a transverse fold in the ante- 
rior wall and incise with the scissors. Continue the longi- 
tudinal slit thus made up as far as the pylorus and down to 
where the duodenum passes beneath the mesentery. Notice 



44 PATHOLOGICAL TECHNIQUE. 

the contents of the duodenum and their color both above 
and below the opening of the gall-duct. The ductus cho- 
ledochus usually opens in common with the ductus pan- 
creaticus on the posterior wall of the duodenum a little 
below the middle of the head of the pancreas, at a point 
marked by a small papilla which can easily be recognized 
by putting the mucous membrane on the stretch transversely. 
Press first on the common duct gently and in the direction 
of the papilla, watching the opening to see if any obstructing 
material is forced out. Pressure is then to be made on the 
gall-bladder to see if its contents also will flow. If neces- 
sary, the common duct and its branches are to be opened in 
situ. In certain cases the ductus pancreaticus is likewise to 
be opened up. 

Several cross-sections of the pancreas are usually better 
than one in the greatest diameter, because the duct is left in 
a better condition for slitting up if necessary. The weight 
of the pancreas varies from 90 to 120 grams (Orth). It 
measures 23 X 4.5 X 2.8 cm. 

The Liver.— The liver is usually the last organ of the 
gastro-intestinal tract to be removed. This is ordinarily 
done by lifting up the right lobe and freeing it from all 
attachments as far as the vertebral column : the right lobe is 
then lifted and placed on the edge of the ribs on the right 
side, while the left lobe is elevated and freed. If the dia- 
phragm is firmly adherent, remove it with the liver. The 
incision to display the liver is a long deep cut passing through 
the right and left lobes in the greatest diameter of the organ. 

In a good many cases it is very convenient to remove the 
liver at the beginning of the special examination of the ab- 
dominal cavity, because more room can be obtained for the 
investigation of the other organs. This latter fault can to 
some extent be obviated by cutting the diaphragm on the 
right side and allowing the liver to slide forward somewhat 
into the right thoracic cavity. 

There can be no objection to the removal of the liver 
when jaundice is not present or when the liver is not con- 
nected by continuity with the lesion of some other organ 



POST-MORTEM EXAMINATIONS. 45 

(pylephlebitis, malignant growth extending through portal 
vein or along gall-ducts, etc.). 

The operation is performed as follows : Pass the left hand 
in between the diaphragm and the right lobe and push the 
liver forward out of the right hypochondrium. Incise it 
deeply in its greatest diameter through the left and right 
lobes. Next free the gall-bladder from its bed by means of 
the fingers, and cut it off near the ductus hepaticus after 
compressing its lower end. It can then be opened length- 
wise and washed without danger of discoloring the liver or 
other organs. The liver is now to be grasped by placing 
the thumb on the under surface of the liver and the fingers 
in the incision. Elevate the organ, and, while carefully 
watching, cut through the ligamentum hepato-duodenal, 
which includes the blood-vessels and the ductus hepaticus. 
The ligamentum hepato-gastrium, the inferior vena cava, the 
suspensory ligament, the ligamentum coronarium, and the 
tissue between the inferior surface of the liver and the upper 
end of the kidney follow next : the adrenal is to be left on 
the kidney, and the diaphragm ought not to be injured. 

Even in the ordinary way of removing the liver the organ 
will be found much easier to handle if the usual incision is 
made in situ, so as to furnish a hold for the left hand. 

Other cuts into the liver are best made parallel to the 
primary one. 

Orth gives the weight of the liver for adults as varying 
from 1000 to 2000 grams. The average weight is usually 
put at 1500 to 1800 grams. 

The liver measurements are as follows : 

Length from right to left . . . • 2 5~3 2 cm - 

Width of right lobe 18-20 " 

Width of left lobe 8-10 " 

Vertical diameter of right lobe 20-22 " 

Vertical diameter of left lobe 15-16 " 

Greatest thickness 6- 9.5 " 

The Kidneys and Adrenals. — If the adrenals are to be 
removed with the kidneys, it is necessary to cut first to the 
inside, and secondly above the adrenal, and then to make 



46 PATHOLOGICAL TECHNIQUE. 

from the outer end of the second cut a curved incision along 
the outer convex border of the kidney through the perito- 
neum and the perinephritic fat-tissue. The left hand is to 
be inserted into the cut, the mass of tissue drawn forcibly 
forward, and the vessels divided as close to the aorta as pos- 
sible, so that the renal vessels may be slit up and examined 
in connection with the renal lesions. The adrenal should be 
incised crosswise. The kidney is to be held firmly in the 
left hand between the thumb and fingers while a longitudinal 
incision is made from the convex border to the hilus. As a 
rule, it is better to shell it out of its investing fat-tissue before 
incising it. 

It will often be found convenient to make simply the curved 
incision above given, to shell the kidney out of its fat-cap- 
sule, and then to divide its vessels, leaving the adrenal behind 
to be incised in situ or removed separately. As a rule the left 
kidney is removed first. 

In all cases in which the bladder is involved in patho- 
logical changes in common with the kidneys the whole 
urinary tract should be removed intact, so that the lesions 
may be examined in continuity. For this reason it is a good 
plan to open up the pelvis of the kidney and the ureter from 
the primary incision, in order to see if any lesion is present 
before dividing the ureter. 

If it is desired to remove the kidneys before the intestines, 
the latter must to some extent be freed from their normal 
attachments. 

The splenic flexure of the colon is first to be drawn for- 
cibly forward and its attachments divided where they hide the 
left kidney. If the ureter is .to be taken out also, it is best 
to free the whole of the descending colon from its mesocolon. 
Then the colon and the coils of small intestine are drawn 
over to the right side of the body, so as to leave the left kid- 
ney and adrenal exposed. They are then removed in exactly 
the same manner as already described. 

To remove the right kidney the hepatic flexure must be 
freed from over it. If the ureter is to be taken out, the de- 
scending- colon and the cecum are dissected from over it. 



POST-MORTEM EXAMINATIONS. 47 

The right adrenal is firmly attached to the under surface of 
the liver, and must be carefully dissected from it by turning 
the latter upward. 

If the urinary tract is to be removed in continuity, each 
ureter is dissected down to the brim of the pelvis, and then 
left with its kidney attached until the pelvic organs have 
been taken out. 

After the kidney has been incised the capsule is to be 
stripped off, at least in part, so that the appearance of the 
surface of the kidney and the presence or absence of adhe- 
sions between the capsule and the renal tissue can be deter- 
mined. 

The points to be noted in the macroscopic examination of 
the kidney are size, consistency, and, on section, color, rela- 
tive proportion of cortex to pyramids, and thickness of each ; 
finally, the normal markings of the kidney, including blood- 
vessels, glomeruli, convoluted and straight tubules of cortex, 
collecting tubules of pyramids. 

The average weight of the kidney is 150 grams. The left 
kidney is always 5 to 7 grams heavier than the right (Orth). 
A kidney measures 1 1-12X5-6X3-4.5 cm. The cortex 
measures in thickness 4-6 mm. The relation of the cortex 
to the medulla is 1 to 3. 

The Pelvic Organs. — The pelvic organs are most easily 
and neatly removed by stripping the peritoneum from the 
pelvic wall with the fingers. Begin over the bladder and 
extend down the sides of the pelvis until the fingers meet 
beneath the rectum. Brace the backs of the hands laterally 
on the brim of the -pelvis and lift the fingers forcibly upward ; 
this movement will free the pelvic organs cleanly from the 
sacrum, and leave them attached only anteriorly at the rectal 
and genital openings, and posteriorly by the peritoneum and 
the vessels at the brim of the pelvis. 

Anteriorly, the attachments may now be divided with the 
knife at whatever point seems advisable, ordinarily close to 
the pubes just anterior to the prostate (or through the ure- 
thra and vagina in females) and through the lower end of 
the rectum. Posteriorly, cut through the tissues at the brim 



48 PATHOLOGICAL TECHNIQUE. 

of the pelvis, taking care not to cut the ureters if the kid- 
neys are still attached to them. The rectum is to be opened 
with the enterotome along the posterior wall, and the inner 
surface thoroughly washed off so as to avoid soiling the 
other organs. 

To open the bladder in males, especially if the penis has 
been removed in continuity with it, incise with the scissors a 
transverse fold in the anterior wall of the fundus, and carry 
the incision through the urethra and along the dorsum of the 
penis. To accomplish the latter act perfectly the penis must 
be firmly stretched by having an assistant pull at the frenum 
while the bladder is held fixed by the operator. 

In females it is usual to enter the scissors into the bladder 
through the urethra and to cut through the middle of the 
anterior wall of the fundus. 

In males the rectum should be dissected from the bladder, 
so as to lay bare the vesiculse seminales and the prostate, 
which are examined by means of several transverse incisions. 

In females, if the bladder is normal, the vagina is incised 
in the anterior wall through the middle of the bladder. Or 
the vagina may be incised laterally until the cervix is reached, 
and then the cut be carried up to the median line. 

The uterus is incised in its anterior wall from the cervix 
to the fundus. From the upper part of this incision second- 
ary incisions are carried out on each side to the orifices of the 
Fallopian tubes. 

The ovaries are incised in their greatest diameter, from the 
convex border to the hilus. Weight of ovaries, 7 grams. 

The testicles can readily be examined without external 
injury to the scrotum by cutting underneath the skin over 
the pubes down to the scrotum on either side of the penis, 
and shoving the testicles up through the incision. Cut care- 
fully through the overlying tissues until the cavity of the 
tunica vaginalis is opened. Remove the testicle by severing 
the cord. The incision to display a testicle should be in the 
long diameter, beginning on the side opposite the epididymis 
and extending through into it. Weight of testicles, 15-24.5 
grams. In cases of tuberculosis of the testis and epididymis 



POST-MORTEM EXAMINATIONS. 49 

it is advisable not to cut through the cord, but to remove 
the testicles and cords with the bladder, so that the whole 
genital tract may be examined in continuity and the asso- 
ciated lesions in the vesiculae seminales demonstrated, if 
present. 

The penis, or at least the larger portion of it, can be re- 
moved in connection with the bladder by continuing the pri- 
mary body-incision out to about the middle of the dorsum 
of the penis, which is then to be freed from the investing 
skin and divided just posterior to the corona. It is next 
dissected back to the pubic arch, and freed from it partly by 
cutting from without, partly from within, the pelvis, until the 
penis can be passed underneath the arch into the pelvis. 
Other methods are to cut through the symphysis, which can 
then readily be sprung apart by swinging one of the legs 
out into a horizontal plane, or even to saw out a small sec- 
tion of bone including the symphysis, so as to have more 
room for freeing the attachment of the penis and for re- 
moving it. 

The structures now remaining in the abdominal and 
thoracic cavities which require examination are the large 
blood-vessels, the thoracic duct, the celiac ganglion, and the 
retroperitoneal lymph-glands. The inferior vena cava and 
its branches are first examined (especially in all cases of 
pulmonary embolism) by slitting them with scissors along 
the anterior wall. If it is necessary to follow the iliac ves- 
sels into the thigh, it will be found easier in sewing upjf the 
primary abdominal incision is continued off to the side in 
question, thus giving a single though curved incision. 

It is sometimes advisable to open up the inferior vena cava 
and its branches before removing the pelvic organs, so that 
thrombi extending into the pelvic vessels may be examined 
before they are disturbed. 

The semilunar ganglia lie on the aorta, around the celiac 
axis, above the pancreas. 

The thoracic duct lies behind and to the right of the aorta. 
In the thorax it is most easily found by dissecting on the 
right side between the aorta and the azygos vein. The re- 
4 



50 PATHOLOGICAL TECHNIQUE. 

ceptaculum chyli lies to the right and behind the aorta upon 
the second or third lumbar vertebra. Examination of the 
thoracic duct is of especial importance in cases of tubercu- 
losis of the intestine and mesenteric lymph-glands with 
secondary miliary tuberculosis. 

The aorta is to be opened in situ along the anterior wall 
throughout its whole extent, and the iliacs as far as the 
femoral ring. 

Besides the brain, the spinal cord, and the thoracic and 
abdominal organs, it is often necessary to examine or remove 
for study other portions of the body that are affected by dis- 
ease. A little ingenuity will enable one in appropriate cases 
to get at almost any part desired. 

A view of the marrow in a long bone is most easily ob- 
tained in the femur by extending the body-incision down 
over one of the thighs, dissecting the muscles way, and then 
chiselling off a portion of the upper part of the shaft. 

In tuberculosis of the spine it is quite easy to remove any 
part, or even the whole, of the vertebral column, including 
the pelvis and portions of the femurs, without other incisions 
than the one from the neck to the pubes, with extension 
down the thighs in case parts of the femurs are to be taken 
out. Divide the ribs a few centimeters from the vertebral 
column on each side of the portion that is to be removed, 
cut through intervertebral disks both above and below it, 
and then carefully dissect it free, taking great care not to 
button-hole the skin. 

Removal of the Brain. — The incision into the scalp 
should begin from one to two centimeters behind the right 
ear, near its lower border, at the edge of the hair, and ex- 
tend over the vertex of the skull to a corresponding point 
behind the left ear. The cut is most easily made by thrust- 
ing a small narrow-bladed scalpel, with its back toward the 
calvaria and its point toward the vertex, through the skin 
behind the ear and shoving it along in the desired direction. 
By making the incision in this manner the hair is not cut, 
but simply parted. The anterior flap should be stripped 
from the calvaria and the temporal muscles by putting it on 



POST-MO R TEM EXAMINA TIONS. 5 I 

the stretch and dividing the loose connective tissue hold- 
ing it by sweeping strokes of the scalpel nearly as far for- 
ward as the orbits. After a part of the flap has been freed 
it is often possible to strip the rest without using the scalpel. 
For the posterior flap, which should be removed back as far 
as the occipital protuberance, the scalpel nearly always has 
to be used. 

If the hair is long, the anterior portion can be rolled into 
the anterior flap over the face and thus protected. The 
posterior portion is gathered at the nape of the neck, and 
then a towel is wrapped tightly around the head and neck, 
extending from the line where the flaps are reflected down 
to the shoulders, and is pinned over the lower part of the 
forehead. In this manner the hair is perfectly protected from 
being soiled and ample room is left for work. 

Of the two methods of opening the skull, the circular and 
the wedge-shaped, the former makes the better museum 
preparation, but the latter is in greater use in this country, 
and has the advantage of rendering the calvaria less likely 
to slip out of place after the head has been sewed up. 

The wedge-shaped incision consists of three cuts, which 
should be outlined on the periosteum of the skull with a 
scalpel. The first cut begins just above and behind the left 
ear, and is carried over the forehead just back of the edge 
of the hair or over the frontal eminences to a corresponding 
point above and behind the right ear. The two other cuts 
begin at each end of the first incision, forming there an 
obtuse angle, and are carried back to meet in the median 
line behind at an angle of about 160 a little in front of the 
occipital protuberance. The temporal muscle on each side 
is now to be scraped back from the line of incision out of 
the way of the saw, but is not to be cut off. The holder, 
if one is used, is attached with a foot in each obtuse angle 
in the temporal region. If a holder is not employed, the 
head is best steadied by hands on the calvaria and face. 
Use towels or cloth to prevent slipping. 

Start the incision with the saw over the forehead and 
extend it back along the line marked out. It is best not to 



52 PATHOLOGICAL TECHNIQUE. 

carry the incision clear through the inner table of the bone, 
for two reasons : first, on account of the danger of injuring 
the brain-substance ; secondly, because if the inner table or 
a part of it is cracked through with a chisel and hammer, it 
can be done without injuring the underlying tissue, and the 
irregular overlapping fragments of bone thereby formed 
serve afterward for holding the calvaria firmly and steadily 
in place. 

After sawing along the lines marked out, insert a chisel in 
the frontal region, and with a quick, sharp blow crack 
through the rest of the inner table. In like manner insert 
the chisel in the middle of the other incisions and free the 
calvaria posteriorly. To remove the calvaria insert the 
chisel end of the hammer in the incision in the frontal 
region, and press down with the left hand while swinging 
the handle around in a horizontal plane. 

By means of the powerful purchase obtained the calvaria 
is easily started. Then catch the hook of the hammer over 
the calvaria and strip it off. If the dura is adherent to the 
calvaria, it may be freed by using the point of the closed 
enterotome to pry it off. 

In young children, and sometimes in old people, it is 
necessary to remove the dura with the calvaria. To do this, 
cut through the dura with the point of a scalpel along the 
lines of incision in the skull ; then cut the falx cerebri in 
the median line, both anteriorly and posteriorly. 

An infant's skull is best opened by cutting with a pair of 
scissors through the dura along the sutures (in the longi- 
tudinal suture on each side of the falx) well down to the 
floor of the skull. This gives five bone-flaps which may be 
turned out like the petals of a flower, leaving the brain unin- 
jured. It is often necessary to cut half of the base of each 
flap in a horizontal line to aid its being turned out. The 
falx cerebri must of course be divided anteriorly and drawn 
back before the brain is removed. In sewing up, the bone- 
flaps are turned in over a bag of sand or sawdust filling the 
cranial cavity, and are kept perfectly in place by the skin. 

In a case of fracture of the skull no cracking with hammer 



POST-MORTEM EXAMINATIONS. 53 

and chisel is allowable ; the calvaria must be freed entirely 
by sawing. The calvaria should be examined at the time of 
removal. 

The next step is to inspect the dura. Under normal con- 
ditions it is not tense in the frontal region, but can be picked 
up with the forceps or fingers. If the dura is not thickened, 
the convolutions normally should be visible through it. The 
longitudinal sinus is opened with knife or scissors and its 
contents examined. Pacchionian granulations are not infre- 
quently found projecting into it. 

To remove the dura, cut through it with scissors or knife 
along the same lines in which the calvaria was sawn. Turn 
back each half of the dura and examine the surface of the 
convolutions and the inner surface of the dura. The con- 
volutions should be distinct and rounded, not flattened, with 
obliteration of the gyri, as occurs when there is internal 
pressure. 

The Pacchionian granulations are situated along the longi- 
tudinal fissure and may grow through the dura and form 
depressions in the calvaria. There may be apparent adhe- 
sions between the dura and pia due to veins passing from 
one to the other. The dura is still further freed by seizing 
the two halves anteriorly and lifting them up until the falx 
is tense at its insertion into the crista galli. Pass a knife in 
parallel to the falx, on the left side, with the edge forward, as 
far as the cribriform plate ; turn it to the right and cut until 
the falx yields. Withdraw the knife in the same manner in 
which it was inserted. Next draw the dura back. It is usu- 
ally more or less attached along the longitudinal fissure by 
Pacchionian granulations and by blood-vessels. These may 
be cut or torn through. Do not cut the dura posteriorly, 
but let it hang down. 

To remove the brain, insert the two fore fingers, or the 
first and second fingers of the left hand, anteriorly between 
the dura and the frontal lobes, one on each side of the falx 
cerebri, and draw the brain gently back until the optic nerves 
are visible. Ordinarily, the olfactory nerves come away from 
the cribriform plate without trouble, but sometimes have to 



54 



PA THOL O GICAL TE CHNIQ UE. 



be freed with the point of the knife. With a long, slender- 
bladed knife divide the optic nerves as far forward as possible 
while holding the brain back with the left hand. Continue 
to draw the brain carefully back and divide the cranial nerves 



Hypo. 



N. trig-em. — Hi 

N. facial J" 

N. acust, 




Carotis int. 



S. cavernos. 



S. petr. inf. 
S.petr.sup. 
Cut edge 
of tento- 
rium. 



N. glossophar. 

N. vagus. /\ 
N. recurr 



N. hypogl. 

Tentorium. 



S. transvers. 
\<4, vertebral. 



Fig. 8. — Base of skull (Nauwerck). 



and the carotids. Then draw forward first the left, then the 
right temporal lobe, and cut the tentorium close to its attach- 
ment to the petrous portion of the temporal bone with a 
sawing motion, using the tip of the knife. Insert the knife 
at the side close to the squamous bone, and cut from there 



POST-MOR TEM EXAM IN A TIONS. 5 5 

in toward the foramen magnum. Then cut the nerves given 
off from the medulla oblongata while supporting the con- 
vexity of the brain in the left hand. 

Lastly, carry the knife as far as possible into the spinal 
canal, and divide the cervical cord by an oblique incision 
from each side, severing the vertebral arteries with the same 
stroke. Better than a knife is the myelotome, because it 
gives a cross-section of the cord and allows more of it to be 
removed. 

The brain is now to be removed by passing the first and 
second fingers of the right hand in on either side of the cord, 
and everting the brain while still supporting it posteriorly 
with the left hand. 

Before proceeding to open the brain it is best to examine 
the base of the skull, particularly the dura, of which the 
sinuses should be incised, and the hypophysis cerebri. 

If there is a suspicion of a fracture at the base, strip off the 
dura, so as to give a better opportunity for examination of 
the bone. 

The brain should be weighed before it is dissected. The 
average weight in an adult male is 1358 grams; in an adult 
woman, 1235 grams. 

External Examination of the Brain. — Place the 
brain with the base uppermost and with the cerebellum to- 
ward the operator. Examine first the pia and the cranial 
nerves, then the arteries, especially the middle cerebral and 
its branches on each side in the fissure of Sylvius, for it is 
here that emboli most frequently lodge. The pia bridging 
the fissure of Sylvius can sometimes be torn through, but 
usually has to be cut. 

It is important, particularly in cases of obscure cerebral 
symptoms, to feel gently with the finger-tips all over the sur- 
face of the brain for any areas of increased density, because 
patches of sclerosis may in that way be found which might 
otherwise be overlooked. 

By stripping off the pia — a procedure not often advisable 
— adhesions over pathological areas can sometimes be found 
pointing to the lesions beneath, but the pia should not be 



$6 PATHOLOGICAL TECHNIQUE. 

stripped from those portions which are to be examined mi- 
croscopically. To remove the pia an incision is made on the 
median surface of each hemisphere just above the corpus 
callosum from one extremity to the other, and the pia 
stripped back first from the median and then from the con- 
vex surface. The stripping is done by means of the fingers, 
with occasional aid from the forceps. 

Section of the Brain. — There are several methods of 
cutting up the brain, no one of which is particularly suitable 
to all occasions. That method must be chosen which is most 
fitted to the individual case and to the use to which the 
tissue is to be put. 

The ideal method from a neuro-pathological standpoint 
would undoubtedly be to harden the brain entire, and then 
to make serial frontal sections thin enough for microscopical 
purposes through the whole organ. The nearest approach 
to this ideal method is to harden the brain entire in formal- 
dehyde, a process occupying ten days to two weeks (see 
page 303), to make thin serial sections, to mordant the sec- 
tions, divided if necessary into smaller pieces, in a chrome 
salt (preferably by Weigert's quick method), and then to 
carry through a number of series from the important parts 
for microscopical examination. By this means the relations 
of the various cerebral structures and of the pathological 
lesions can be perfectly preserved and studied. This method 
can be particularly recommended for tracing degenerations 
in the motor tract. 

If there is a noticeable focal lesion, such as a tumor or 
hemorrhage, it should be so incised, generally frontally or 
horizontally, as best to show its relations to the important 
cerebral tracts and ganglia. In these cases also the best re- 
sults are obtained by hardening the brain entire in formal- 
dehyde, and later making serial sections for macroscopic 
study or for carrying through for histological purposes. In 
many cases, however, it is necessary or advisable to examine 
the lesions in the fresh state. For instance, if it be desired 
to study the neuroglia-fibers, it is positively necessary to cut 
out thin slices of fresh tissue and to fix them immediately in 



POST-MORTEM EXAMINATIONS. 



57 



the proper solution. Often, too, the lesion cannot be or is 
not found except on fresh examination, or the clinician whose 
case it is desires to see at once the cause of certain symp- 
toms. Under such circumstances the more ideal method 
must be sacrificed, and as much made out of the case as is 
possible in the condition in which it is left after the exami- 
nation. 

For the routine examination of the brain, to demonstrate 



S. call marg 



G.forn. G. front. I. 

G. front. II. 

mmL G ' fro " 




G. centr. a. 
S. Rol. 
G. cenlr. p. 



G. marg. 
G. ang. 
. inter par. 
L. par. sip. 

par. occ. 
C. call. 
Fig. 9. — First cut in the brain (Nauwerck). 

its topography and to bring to light suspected or unsus- 
pected lesions, probably no method is more generally used 
than Virchow's. The objection most often made against it 
is that the cerebral cortex is too much cut up. In case, 
however, it is desired to preserve the cortex or parts of it for 
microscopic purposes, the longitudinal incisions after the first 
may be omitted, and the cortical portion, after being sepa- 
rated from the stem, may be cut in any way that seems ad- 
visable. In like manner, the brain-stem or any other part 



58 PATHOLOGICAL TECHNIQUE. 

may be left uncut, and hardened entire in formaldehyde for 
histological purposes. 

Virchow's Method. — The brain is to be placed on its base 
in the same position as one's own. Press the hemispheres 
apart a little so as to expose the corpus callosum. Hold the 
left half of the cerebrum in the left hand with the fingers on the 
lateral aspect and the thumb in the longitudinal fissure. Then 
make an almost vertical incision with a long, slender knife 
through the roof of the left ventricle in its middle third, 2 to 
3 mm. from the median raphe of the corpus callosum. The 
roof of the ventricle is to be slightly raised vertically by the 
thumb, so that the incision, which must not be too deep, may 
not injure the basal ganglia. The incision is to be continued 
into the anterior and posterior cornua. Then make a long 
incision from one end of the above cut to the other, passing 
just outside of the basal ganglia at an angle of about 45 °. 
Repeat the process on the right side, turning the brain half 
around. Next seize what remains of the corpus callosum 
and fornix in the middle, lift them, and cut through from be- 
low up, passing the knife through the foramen of Munroe. 
The parts are then turned back, exposing the velum inter- 
positum and the choroid plexuses. By drawing back the 
velum interpositum the third ventricle is uncovered. 

The corpora quadrigemina are exposed by cutting trans- 
versely the right posterior pillar of the fornix and adjoining 
brain-substance and carrying them over to the left. Each 
ventricle as it is opened is to be carefully inspected and any 
abnormal condition of its ependyma noted. The cortex is 
further divided on one side, and then on the other, by hold- 
ing it in the left hand and making vertical straight sections 
from the upper angle of the previous cut into the convex 
cortex, allowing the sections to fall apart, so as to avoid 
touching and soiling the surface with knife or fingers. Each 
portion thus cut represents a prism. The incisions should 
go well into the cortex, but not so far as to separate the 
different pieces. The basal ganglia are examined by means 
of a number of frontal sections. For this purpose the left 
hand is placed palm upward underneath the brain, so that as 



POST-MORTEM EXAMINATIONS. 



59 



each section is made over the tips of the ringers by one long 
stroke of the knife it falls forward, exposing a clean surface 
of which the two halves can be compared. An incision is 
next carried through the middle of the pineal gland, the 
corpora quadrigemina, and the vermiform process of the 
cerebellum, opening the aqueduct of Sylvius and the fourth 
ventricle. 

Each half of the cerebellum is divided by a median hori- 



Corp. call. 




Cr.forn. desc. 



Cr.forn. desc. 
Fig. io. — Section of the brain (Nauwerck). 



zontal section into halves, and these portions are still further 
subdivided by a series of cuts radiating from the peduncles. 

In order to make sections of the pons and medulla the 
brain is folded together and turned over. Several cross- 
sections are then made with the left hand placed beneath as 
in sectioning the basal ganglia. 

Before making the sections it is well to remove the basilar 
and vertebral arteries, especially if they are calcified. 

In Pitre's method of dissecting the brain the lateral ven- 
tricles are opened as in Virchow's method. Then the pedun- 
culi cerebri are cut squarely across, so as to remove the pons 



60 PATHOLOGICAL TECHNIQUE. 

and cerebellum, and a longitudinal incision is carried down 
through the third ventricle, halving the cerebrum. Through 
each half of the cerebrum a series of six sections is then 
made parallel to the fissure of Rolando. The names of the 
sections and the important parts which they show are as 
follows : 

1. The pre-frontal section through the frontal lobe, 5 cm. 
anterior to the fissure of Rolando, shows the gray and white 
substance of the frontal convolutions. 

2. The pedictdo-frontal section through the posterior por- 
tions of the three frontal convolutions shows the anterior 
extremity of the island of Reil, the lenticular and caudate 
nuclei, and the internal capsule. 

3. The frontal section through the ascending frontal con- 
volution, parallel to the fissure of Rolando, shows the optic 
thalamus, the lenticular and caudate nuclei, the claustrum, 
the external and internal capsules, the anterior portion of the 
descending horn of the lateral ventricle, and the island of 
Reil. 

4. The parietal section through the ascending parietal con- 
volution shows portions of the same structures as the pre- 
ceding, and a transverse view of the hippocampus. 

5. The pedicnlo-parietal section through the parietal lobe, 
3 cm. posterior to the fissure of Rolando, shows the tail of 
the caudate nucleus in two places and the posterior portion 
of the optic thalamus. 

6. The occipital section through the occipital lobe, I cm. 
in front of the parieto-occipital sulcus, shows simply the 
white and gray matter of the occipital lobe. The cere- 
bellum, pons,* and medulla are incised in the manner already 
described. 

Removal of the Spinal Cord. — The body is to be 
placed face downward, with the head over the end of the 
table and a block under the chest. The incision is made 
over the spinous processes from the occiput to the sacrum. 
Dissect the skin and muscles back on each side, so as to 
leave the vertebral laminae as bare as possible. The laminae 
may be cut through by means of several instruments, of 



POST-MORTEM EXAMINATIONS. 6 1 

which the double-bladed saw (Luer's rhachiotome) is perhaps 
the safest, at least for beginners. The single-bladed saw 
with rounded end is also very useful and can be thoroughly 
recommended. The operation can be done most quickly by 
biting off the spinous processes with the heavy bone-forceps 
and cutting through the laminae with chisel and hammer, 
but there is greater danger of injuring the cord. 

The numerous artifacts in the cord, reported as neuromata 
and heteroplasia even within very recent times by competent 
pathologists, would seem to indicate that the need of careful 
and delicate technique in the removal of the spinal cord is 
not yet fully appreciated. 

The laminae should be sawn nearly or entirely through in 
a line with the roots of the transverse processes from the 
third or fourth lumbar vertebra to the cervical region. The 
arches of the cervical vertebrae are best divided with a heavy 
bone-cutter, because they cannot be easily sawn, and there 
is sufficient room here for the points of the bone-cutter with- 
out danger of their pressing on the cord. 

It is important to strike the outside limits of the spinal 
canal, so as to get as much room as possible for the removal 
of the cord. Test if the sawing be deep enough by the 
mobility of the spinous processes. If necessary, they can 
be freed by means of the hatchet-chisel and a hammer in 
the same way that the calvaria is loosened. 

As the cord reaches only to the second lumbar vertebra, 
cut through between the third and fourth, free with the 
heavy bone-cutter the lower end of the row of the spinous 
processes, which are held together by their ligaments, and 
strip them up to the neck ; then cut through the cervical 
arches with the bone-cutter, taking care that the point 
within the canal does not come in contact with the cord. 

The nerve-roots are to be divided with a sharp scalpel by 
means of a long cut on each side of the cord. Then cut 
across the dura and the nerve-roots at the lower end of the 
exposed canal, and, while holding the dura with forceps, 
carefully free the cord from below up with scissors or scalpel, 
taking care all the time not to pull or bend the cord, be- 



62 



PA THO L O GICA L TE CHNIQ UE. 



cause in either way artifacts may be produced. Cut the cord 
squarely across as high in the cervical canal as possible, so 
that the remaining portion may be easily removed with the 
brain. 

Lay the the cord after removal on a flat surface and incise 
the dura longitudinally, first posteriorly and then in front. 
A series of cross-sections, usually I to 2 cm. apart, is made 
through the cord while supported on the fingers during the 




Fig. ii. — Base of skull, showing lines of incision for removing internal eye, etc. 

(Nauwerck). 



cutting, so that the cut surfaces shall fall apart. The dif- 
ferent segments should ordinarily be left attached to the 
dura, so that their position in the cord can easily be deter- 
mined. 

A diagnosis from the fresh, macroscopic appearances of 
the cord is often very difficult to make, according to the best 
authorities. 

The Eye. — The contents of the orbit, including the poste- 
rior part of the eye, can be readily examined by chiselling 



POST-MORTEM EXAMINATIONS. 63 

off the roof of the orbit. The posterior half of the eye can 
be removed by cutting around the eyeball with sharp scissors 
without changing the hold of the forceps on the sclera. If 
done quickly, the retina remains quite well spread out. The 
anterior half of the eyeball is to be propped in place by a 
plug of cotton dipped in ink or in a solution of perman- 
ganate of potassium. 

The 3$ar. — The middle ear can be exposed by chipping 
off with a chisel its roof, which lies in the middle of the 
petrous portion of the temporal bone. The roof can also 
be very easily bitten off with the heavy bone-cutters. If, how- 
ever, it be desired to examine the ear more carefully by 
means of a section through the external meatus and the 
middle ear, it will be necessary to remove the whole of the 
petrous bone. For this purpose the incision behind the ear 
must be carried back along the anterior edge of the trapezius 
muscle halfway down the neck. Then the skin-flaps, in- 
cluding the external ear and the underlying tissues, must be 
dissected back for some distance on each side of the incis- 
ion. Two converging incisions are then to be sawn, the 
anterior passing through the root of the zygomatic arch, 
the posterior just back of the sigmoid sinus, so as to come 
together at the apex of the pyramid of the petrous bone, or, 
better still, to meet in the foramen magnum. An ordinary 
chisel and a hammer or mallet will be found very convenient 
for freeing the petrous bone after the incisions have been 
sawn. 

In the examination of the petrous bone after it has been 
removed the first step is to chisel off the tegmen tympani so 
as to get a view of the middle ear. Next remove the lower 
wall of the external meatus, so as to expose the outer sur- 
face of the membrana tympani. Finally divide the petrous 
bone with a fine hair-saw by an incision starting in at the 
styloid process and coming out at the carotid canal, parallel 
to the crest of the pyramid of the petrous bone. 

This incision divides the cavum tympani into halves. In 
the lateral half can be seen the membrana tympani with the 
hammer and the anterior half of the mastoid cells. In the 



64 PATHOLOGICAL TECHNIQUE. 

median half are the labyrinthine wall of the cavum tympani 
with the stapes and the posterior half of the mastoid cells. 
It is best to remove the anvil before sawing through the 
bone. The Eustachian tube can be easily exposed by start- 
ing from its termination in the middle ear. 

The Naso -pharynx. — Although a fair view of the nares 
and pharynx can be obtained by chiselling off the portion 
of the base of the skull lying over them, the method does 
not begin to offer the satisfactory view that can be obtained 
by the method of Harke, 1 a method which is not so difficult 
as might at first sight seem, and which consists in halving the 
base of the skull by a longitudinal incision. To do this the 
original incision in the scalp must be extended on each side 
over the mastoid processes and along the anterior edge of 
the trapezius muscle to a point below the middle of the neck. 
Then the posterior flap and the underlying muscles must be 
freed from the occipital bone and the upper portion of the 
occipital vertebrae. In like manner, the anterior flap must 
be dissected from over the root of the nose and the upper 
edge of the orbits, and be drawn down over the face. Then 
flex the head strongly forward and saw through the occipital 
bone and the base of the skull, dividing the occipital and 
frontal bones, the sella turcica, the cribriform plate, and the 
basilar process into equal halves. Anteriorly, it is well to 
go a little to the left or right, so as not to injure the nasal 
septum. 

The next step is to cut the pachymeninx and the appara- 
tus ligamentosis between the anterior edge of the foramen 
occipitale magnum and the processus odontoideus, as well 
as the inner side of the atlanto-occipital joint from within. 
Then the two halves of the skull are to be drawn forcibly 
apart. The nasal bones, the hard palate, and the alveolar 
process of the upper jaw break, and the two halves of the 
base of the skull open like a book, revolving around an axis 
which passes through the joint of the lower jaw and the 
atlanto-occipital joint. 

If the foramen occipitale magnum offer too much resist- 

1 Berliner klin. Wochenschrift, 1 892, No. 30. 



POST-MORTEM EXAMINATIONS. 65 

ance, break through it with a chisel, and also if necessary 
through the anterior and posterior arches of the atlas. 

It is now easily possible to inspect the sinus sphenoidales, 
the nasal septum, the frontal sinuses, and the nasal passages. 
The antrum of Highmore is easily opened with forceps and 
a pair of bone-shears. 

After the operation the two halves of the base of the skull 
are brought together, and wired if necessary. When the 
skin-flaps have been replaced all evidence of the operation is 
covered up. 

Examination of New-born and Very Young- Chil- 
dren. — 1. The head is preferably opened by the method given 
on page 52. 

2. According to Nauwerck, the spinal canal can be opened 
by dividing the vertebral arches with strong scissors. 

3. The umbilical cord, if present, and the umbilical arte- 
ries demand close attention in children who have lived a few 
days or weeks, for the purpose of determining if infection has 
taken place at that point. Nauwerck advises a modification 
of the primary long incision. A little above the umbilicus 
it should divide into two diverging incisions running to the 
pubes. In this way a triangular flap is left containing the 
umbilical arteries, while from the upper end is given off the 
umbilical vein. The vessels may be ligated or opened at 
any point that seems advisable. 

4. Anomalies of circulation should be looked for in all 
" blue babies." The closure or non-closure of the ductus 
Botalli (arteriosus) is best determined in situ by dissecting 
off the thymus and opening up the pulmonary vein in the 
middle of its anterior surface. The cut may be extended 
downward, if desired, through the pulmonary valve and the 
wall of the right ventricle. The duct lies in the median line 
of the pulmonary artery, a little above its division into its 
two main branches. A small probe can be passed through 
it into the aorta. The condition of the foramen ovale be- 
tween the auricles is easily examined. 

For other anomalies of the circulation it will usually be 
found most satisfactory to remove the thoracic organs in 
5 



66 PATHOLOGICAL TECHNIQUE. 

mass, so as to be able to open up the heart and the vessels 
given off from it before any of the vessels have been severed 
from their connections. 

5. In medico-legal cases especially it is important to de- 
termine whether or not a child has breathed. The main 
steps of the process are as follows : 

(a) Position of the diaphragm before the chest is opened. 
When the lungs are fully distended it is at the fifth or sixth 
rib on the right and at the sixth rib on the left. When the 
lungs contain no air or are but partially distended the 
diaphragm reaches to the fourth rib. 

(b) Ligate the trachea above the sternum before opening 
the thorax. 

(c) After examining the heart, etc., divide the trachea above 
the ligature and remove the thoracic organs in one piece. 

(d) Dissect off the thymus gland and the heart, and place 
the lungs in a large dish of clear cold water to see if they 
will float or not. 

(e) Incise the lungs and notice if they crepitate ; squeeze 
the lung-tissue gently, and see if bubbles of air mingle with 
the blood on the surface, or squeeze the lung beneath water 
and observe if bubbles of air rise to the surface. Decompo- 
sition may give rise to gas in the lungs. 

(/) Divide the lungs into lobes, and then into small 
pieces, and determine if any of them will float. 



Table of the Weight 


and Length of 


the 


Fetus at each Month 


of Gestation (from v. 


Hecker, cited 


by Nauwerck). 


Time in months. 




Weight. 




Length. 


2 




4gr- 




2.5-3 cm. 


3 




5-20 " 




7-9 " 


4 




120 " 




10-17 " 


5 




284 " 




18-27 " 


6 




434 " 




28-34 " 


7 




1218 " 




35-38 « 


8 




1549 " 




39-41 " 


9 




1971 " 




42-44 " 


10 




2334 " 




45-47 " 



6. The long bones should be incised, so as to expose the 



POST-MORTEM EXAMINATIONS. 6 J 

epiphyseal line, which should be examined for evidences of 
congenital syphilis. The ends of the femur and tibia at the 
knee are usually chosen. For making the incision a fine 
hair-saw is preferable to a knife, because the latter often 
causes the bone to break apart at the epiphyseal line. 

The age of the fetus in months can be determined after 
the fifth month by dividing the length in cm. by 5. 

Weight of Organs in a New-born Child. 

Brain 380 gr. (Bischoff). 

Thymus 14 " (Friedleben). 

Heart 20.6 « (Thoma). 

Lungs 58 " 

Spleen 11.1 " 

Kidneys together 23.6 " (Thoma). 

Testicles 8 " 

Liver 118 " 

Restitution of the Body. — After an autopsy is finished 
it is necessary to put the body into such a condition that no 
evidence of the operation will be noticed except on careful 
inspection. All fluids should be removed from the cavities. 
Organs not required for further examination should be re- 
placed. The brain is placed in the body-cavity because it is 
usually impossible to restore it to the skull. The best mate- 
rial for filling up the cavities is fine sawdust. It packs easily 
and smoothly, absorbs well, keeps the needle dry so that it 
does not slip, and does not interfere with sewing like oakum, 
which gets into the stitches. In private autopsies any make- 
shift, such as bran, newspapers, or cloth, must be employed. 
If the pelvic organs have been removed, stuff the pelvis 
tightly to prevent leakage. The cranium may be left empty, 
although it is usually better to pack a little sawdust or other 
material into the base of the skull and the upper part of the 
spinal canal to prevent leaking. Sometimes it is advisable to 
fill the cranial cavity with sand or sawdust wrapped tightly 
in a cloth, of which the edges are brought together and 
twisted so as to crowd the material into a compact mass. If 
the thoracic cavity is well packed with sawdust, the sternum 
will stay perfectly in place without being sewed. 



68 PATHOLOGICAL TECHNIQUE. 

If part of the vertebral column has been removed, a stick 
or heavy iron rod should be run into the spinal canal above 
and below, so as to stiffen the body and hold it in position 
while it is filled about half full of plaster of Paris. After 
this has set there is little danger of the body losing its form. 

In sewing up the body-cavity, begin at the neck. Use a 
piece of twine a little over one and a half times the length 
of the incision. Take one stitch and fasten the end with a 
simple knot or with a surgeon's knot. Turn the loose end 
in under the skin. Hold the attached end of the twine taut 
with the left hand about 8 to 10 cm. from the line of incis- 
ion. The needle is then passed from within outward through 
the edge of the flap and in a diagonal line from below up- 
ward. The stitches should be from I to 2 cm. apart, and 
about the same distance from the edge of the flap. The ob- 
ject of keeping the end of the twine taut is to keep the 
sutures tight and the edges of the flaps up so that the needle 
can be thrust in easily. 

Arrived at the lower end of the incision, take two button- 
hole stitches and draw them tight. Then take a long stitch 
off to one side and cut the twine close to the skin, so as to 
bury the end of it deeply and securely. 

If in removing the calvaria the precaution is taken to crack 
at least a part of the inner table with the chisel and hammer, 
projecting pieces of bone are usually left which interlock and 
hold the calvaria snugly in position when it is replaced. It 
is further fastened by sutures on each side through the fascia 
of the temporal muscle. It is always more difficult to sew 
up the incision in the scalp than the one in the body, especi- 
ally when the hair is long. Care should be taken to bury 
the ends of the suture securely. 

The skull of a child is so thin that it is usually best to 
wire the calvaria in place or fasten it by means of double 
tacks, otherwise it may slip out of place after the scalp has 
been sewed up. 

Slee's ingenious method deserves mention. The usual 
saw-cuts in the skull over the ear are allowed to cross each 
other, so that slits about an inch long are formed in the tern- 



POST-MORTEM EXAMINATIONS. 69 

poral bone. An ordinary roller bandage is stretched across 
the skull and crowded edgewise into the slits. Then the cal- 
varia is replaced and the ends of the bandage are tightly 
overlapped over the vertex and secured by pins. 



List of Works Consulted. 

BLACKBURN : Manual of Autopsies, 1892. 

Chiari : Pathologisch-anatomische Sectiotistechnik, 1894. 

Delafield AND Prudden : Pathological Anatomy, i8< 

Gannett : Post-mortem Examinations, 1887. 

HEKTOEN: Post-mortem Technique, 1894. 

NAUWERCK: Sectionstechnik, 1891. 

Orth : Diagnostic, 1894. 



PART II. 
BACTERIOLOGICAL EXAMINATIONS. 




STERHjaflG CH/WKR 



I. BACTERIOLOGICAL APPARATUS. 

In this section are given certain hints in regard to the 
more important pieces of apparatus which may be found 
useful. 

Steam Steriliser. — The most satisfactory and most 

practical form for laboratory 
purposes is the Arnold steam 
sterilizer No. 5 (Fig. 12). Care 
should be taken to see that the 
holes for the admission of water 
into the space in the double 
bottom do not become plugged 
with sediment. If this occurs, 
not only is an insufficient 
amount of steam generated, but 
the solder of the joints of the 
bottom may be melted. 

Hot-air Steriliser. — A spe- 
cial point in the construction of 
this apparatus is that it should 
be provided with a removable 
metal plate in its bottom, against 
which the flame of the burner impinges, and thus the burn- 
ing out of the iron bottom is prevented. When this plate 
is burnt out, a new one may be substituted. A satisfactory 
form of this apparatus is made by Keen & Haggerty of 
Baltimore and by Peter Gray, 1 1 Marshall st., Boston. 
Blood-serum Coagulator. — This consists of a copper 

70 




Fig. 12. — Arnold's steam sterilizer. 



BACTERIOLOGICAL EXAMINATIONS. J\ 

box with double walls on sides, top, and bottom, provided 
with tightly-closing doors on one side. The space between 
the walls is about two inches wide and is filled with water. 
Heat is applied by a sufficient number of gas-flames, placed 
beneath, to raise the temperature to 85 ° or 95 ° C. The inte- 
rior is fitted with shelves, upon which are placed in a slant- 
ing position the test-tubes containing the blood-serum to be 
coagulated. In the top are openings for thermometers, for 
the introduction of water, etc. Good dimensions are 20 X 
14 X 14 inches, outside measurements. In using the ap- 
paratus time may be saved in heating the water by filling 
the water-jacket with hot water from a hot-water tap. To 
facilitate the removal of the water a small faucet should be 
let into the outer wall near the bottom. 

Gas-Stove. — This is used for boiling culture-media and 
in the cleansing of test-tubes. It may also be used to heat 
the "blood-serum coagulator." The stove should have a 
radial burner which gives a steady blue flame. 

Test-tubes. — The most convenient size is 1.80 X 16 cm., 
or 6 X f in. 

Hypodermic Syringes. — The most useful and durable 
have an asbestos packing and a glass barrel prolonged into 
a nipple with a ground surface, upon which the needle fits 
by means of a cap. These can be sterilized by steam with- 
out impairment of their efficiency. 

Cornet cover-glass forceps (Fig. 13) should be so con- 




Cornet's cover-glass staining forceps. 



structed that the jaws close at an angle between 90 and 
180 . This prevents the annoying draining off of the stain- 
ing solution from the coverglass. 

Dropping-bottles (Fig. 14).— These are very useful for 
holding the staining solutions. The form known as the " T. 
K: patent " is the best. 



72 



PA THOL GICA L TE CHNIQ UE. 




Fig. 14. — Droppim 
bottle. 



The " platinum wire " or " loop " consists of a piece 
of platinum wire of about 22 gauge, 2 ]/ 2 to 3 inches long, fixed 
in the end of a small glass or metal rod 8 
or 10 inches long. It is often of great con- 
venience to have two of these instruments, 
one with the wire curled into a simple loop 
about 1 to 2 mm. in diameter at the free end, 
and the other a straight wire with the free 
extremity hammered flat into a very small 
spatula. The latter is of great utility in 
picking up minute portions of bacterial 
colonies. 

For cultures from tissues a stouter plati- 
num wire, mounted on a metal rod, is de- 
sirable. The wire should be about 2-§- 
inches long, of a thickness of about 1.2 mm., and should 
have its free extremity flattened so as to form a small 
spatula, as in the case of one of the thinner wires above 
mentioned. 

Bacterial Filtering Apparatus. — Various forms of 
this apparatus can be obtained from the dealers. In all, the 
fluid from which the bacteria are to be removed is drawn 
through an unglazed porcelain cylinder into a receiving flask 
by means of a vacuum-pump attached to a water-faucet 
which exhausts the air in the receiving flask. It is usually 
well to connect a Woulff bottle or a vacuum-flask between 
the pump and the receiving flask, to intercept any water 
which may come from the pump. 

For filtration of small quantities the apparatus known as 
the Kitasato filter (Fig. 15) is perhaps as satisfactory as any. 
Before using, the entire apparatus should be sterilized for 
half an hour in the steam sterilizer. 

Wire Baskets. — These are used for holding test-tubes 
during the process of sterilization. They are very cheaply 
made out of a moderately stout galvanized-iron wire netting 
of \ to f inch mesh. They should be of two forms — 
viz. round and square. The round form should be of suf- 
ficient diameter to fit easily into the Arnold steam sterilizer. 



BA CTERIOL O GICAL EXAMINA TIONS. 



73 



The square form should be made to fit the hot-air sterilizer. 
Each form should be 10 or 12 inches deep. 

Tin Cups.— These are used for holding test-tube cul- 
tures upright in the thermostat. In the bottom of each cup 
a layer of cotton should be placed to prevent the breaking 
of the tubes. 



1 




I 



L 



m 



Fig. 15. — Kitasato's filter : a, 
porcelain bougie ; b, attachment 
for suction-pump ; c, reservoir ; 
d, sterile receiver. 



Fig. 16. — Thermo-regulators. 



Thermo -regulator (Fig. 16). — The simple form known 
as the " Reichert " is recommended. 



II. CULTURE=MEDIA. 

Culture-media consist of various nutritive substances, 
either liquid or solid, in or upon which bacteria will grow 
and multiply, and are, as a rule, contained in test-tubes ready 
for use. 

The nutritive material in these test-tubes must be free from 



74 PATHOLOGICAL TECHNIQUE. 

living bacteria — i. e. " sterile " — and must be kept so until 
used. This is accomplished by inserting a stopper of raw 
cotton into the mouth of each test-tube to exclude the en- 
trance of bacteria from without, and then subjecting the 
tubes and their contents to the sterilizing action of live 
steam for the purpose of killing any bacteria which may 
have gained access to the medium during its preparation. 

The Preparation of Test-tubes. — New test-tubes 
should be washed in a very dilute solution of nitric acid 
(2-5 c.c. of the commercial nitric acid to the liter of water), 
then thoroughly rinsed in water and allowed to drain until 
dry or nearly so. The object of the use of the nitric acid is 
to remove any free alkali which may be present in the new 
tubes. 

Old test-tubes containing culture-media, after removal 
of the cotton stoppers, should be boiled for from half an 
hour to one hour in a solution of common soda (4-6 per 
cent.). This treatment not only destroys bacteria, but it also 
loosens and liquefies the material in the tubes, so that it may 
be easily removed with the aid of a test-tube brush and 
plenty of water. 

When all the material has been removed from the test- 
tubes in this way, they are to be rinsed in clean water, then 
in the dilute nitric acid of the strength above indicated for 
the new test-tubes, and finally again rinsed in clean water, 
after which they are to be allowed to drain until dry or 
nearly so. 

The test-tubes thus prepared are next to be provided with 
stoppers of raw cotton (not absorbent cotton), which are to be 
inserted into the mouths of the tubes for a distance of about 
3 cm., and should fit the walls of the tubes smoothly. The 
stoppers should not be packed in nor fit too tightly, but be 
just firm enough in position to easily sustain the weight of 
the tube when it is lifted by the projecting portion of the 
cotton. 

The stoppered tubes are then to be packed into a square 
wire basket which fits into the hot-air sterilizer, and heated 
in this, with the door closed, until the temperature reaches 



a 



u 



BACTERIOLOGICAL EXAMINATIONS. J 5 

about 150 C. The object of this heating is not to sterilize 
the tubes and cotton stoppers, but to mould the stoppers to 
the shape of the test-tubes, so that they can readily be re- 
placed when removed in the subsequent filling of the tube 
with nutritive material. In packing the tubes into the square 
wire basket as many as possible should be placed with the 
cotton stopper uppermost, and the remainder of the space in 
the basket above the tubes may be filled with tubes placed 
on their sides. 

PREPARATION OF CULTURE=MEDIA. 

Bouillon. — Formula for 1000 c.c. : 

Lean beef, 500 grams ; 

Or extract of beef, 3 

Pepton, 10 

Sodium chlorid, 5 

Water, 1 000 c.c. 

500 grams, or about 1 J pounds, of lean beef, finely minced, 
which can be obtained- in the shops under the name of 
Hamburg steak, is thoroughly mixed with 1000 c.c. of ordi- 
nary tap-water and allowed to stand over night or for some 
hours in a cool place. The mixture is then boiled in a sauce- 
pan over the gas stove for about half an hour, and next 
filtered through filter-paper to obtain the clear infusion of the 
beef free from the coagulated albumin and shreds of tissue. 
This clear beef-infusion is then turned back into the sauce- 
pan, which should be clean, and to it are added 10 grams of 
pepton (Witte) and 5 grams of sodium chlorid. The mix- 
ture is next to be boiled until all these substances are dis- 
solved, stirring frequently with a glass rod, and is then to be 
neutralized, for it has a decidedly acid reaction from the acid 
of the meat. 

The neutralization is important and requires care. The 
reaction required is that of a very faint alkalinity, as is 
shown by the production of a blue color on red litmus-paper, 
while no change is produced on the blue litmus-paper. In 
neutralizing, a 10 per cent, solution of caustic soda is added, 
a few c.c. at a time at first, and later, two or three drops at a 



6 PATHOLOGICAL TECHNIQUE. 



time, while the mixture is kept boiling, the reaction being 
tested between each addition of alkali after thorough stir- 
ring with a glass rod. 

The test of the reaction is best made by placing a drop of 
the mixture on a piece of litmus-paper by means of the 
glass rod and then moistening the paper at the water-faucet. 
In this way the best judgment can be formed of changes in 
the color of the paper. If the mixture becomes too alkaline, 
dilute hydrochloric acid is to be added to correct this. 

When the proper reaction has been obtained the mixture 
is to be filtered through filter-paper into a flask, and suf- 
ficient water added to bring the volume of the filtrate up to 
iooo c.c, thus replacing the loss by evaporation. The fil- 
trate in the flask is now bouillon. If the bouillon be heated 
to the boiling-point, it will usually become more or less 
clouded by a precipitate of phosphates. As a rule, subse- 
quent heatings do not cause any further precipitations. 
Therefore it is advisable, if the bouillon is designed for use 
as bouillon cultures, to steam the flask containing the freshly 
prepared bouillon in the steam sterilizer for about half an 
hour, and then, if the bouillon be clouded, to again filter, so 
that the subsequent sterilizations in the test-tubes will not 
cause precipitates. 

For bouillon cultures the bouillon is run into test-tubes, 
each tube being filled to a depth of about 4 cm., and steril- 
ized immediately and on the two following days, according 
to the general directions given on page 87, after which it is 
ready for use. 

Bouillon may also be made as above indicated by using 
three grams of Liebig's extract of beef to the liter, instead 
of the beef-infusion. 

Glucose Bouillon. — Formula : 

Glucose (dry), 10 grams ; 

Lean beef, 500 

Or extract of beef, 3 

Pepton, 10 " 

Sodium chlorid, 5 

Water, 1000 c.c. 



BACTERIOLOGICAL EXAMINATIONS. J J 

This medium is identical with the preceding, except that it 
contains 10 grams of glucose to the liter (i per cent) in ad- 
dition to the other ingredients. The preparation of glucose 
bouillon is the same as that of plain bouillon, the glucose 
being added with the pepton and sodium chlorid. 
Agar-agar (plain). — Formula for iooo c.c. : 



Agar-agar, 


15 grams; 


Lean beef, 


500 


Or extract of beef, 


3 " 


Pepton, 


10 


Sodium chlorid, 


5 " 


Water, 


IOOO c.c. 



Agar-agar is essentially bouillon in which agar-agar 'has 
been dissolved so that a transparent jelly is formed. The 
function of the agar-agar is merely to give the medium the 
property of becoming liquid when heated and solid when 
cool ; it is not nutritive. The nutritive substances are in the 
bouillon. 

To make one liter, 15 grams of agar-agar are placed in a 
liter of bouillon and boiled for one hour in a saucepan. The 
agar-agar dissolves slowly, and continuous boiling is neces- 
sary to ensure its subsequent filtration. Before boiling about 
200 c.c. of water should be added to compensate for evap- 
oration, and later, as the level of the liquid falls, more water 
should be added from time to time. It is well to have some 
mark on the side of the saucepan which will indicate the 
level of a liter. 

After the boiling is completed the saucepan is to be placed 
in cold water until the temperature of its contents falls 
to about 6o° C, as shown by the thermometer, the cooling 
being facilitated by stirring with a glass rod. When this 
temperature is reached, an egg is beaten into the mass and 
the saucepan with its contents replaced on the stove, where 
it is slowly brought to boiling and boiled for about ten min- 
utes. The object of the adding of the egg is to clarify the 
medium. It is then filtered, boiling hot, through wet folded 



78 



PA THOL O GICAL TECHNIQ UE. 



filter-paper into a flask. A funnel with corrugations on its 
sides is best to use. With this the folding of the filter-paper 
is not necessary. 

In order to save time, it is best to use two filters and two 
flasks at once, for the filtration rapidly becomes slow as the 
mass cools, and several heatings of the residue on the filter 

are necessary. As soon as the fil- 
trate begins to appear slowly, drop 
by drop, the mass remaining on 
the filter should be turned back 
into the saucepan — which can best 
be done by making a hole in the 
bottom of the filter with the glass 
rod — and brought again to boiling. 
While boiling hot it is again poured 
on a fresh filter. This preparation 
of fresh filters and reheating may 
have to be repeated several times 
before all of the mixture is filtered. 
The filtration may also be carried 
on in the steam sterilizer to pre- 
vent the cooling of the medium. 

When the amount of coagulated 
egg-albumin and medium remain- 
ing on the filter does not exceed a 
volume of 50-100 c.c, the filtra- 
tion may be considered complete. 
To the filtrate, which is now agar- 
agar, is next added sufficient water 
to make up the loss by evaporation, 
and the medium is then to be run 
into test-tubes and sterilizd, as described on page 86. 

Precipitates of phosphates in the medium frequently occur 
after the first sterilization, but if these be removed they do 
not usually appear again in subsequent heatings. Therefore, 
if it be desirable to obtain a very clear agar-agar, it is well to 
place the flask containing the freshly-prepared medium in 
the steam sterilizer for half an hour, and then filter again to 




Fig. 17.—" Stab " culture (a) 
" slant" culture (b). 



BACTERIOLOGICAL EXAMINATIONS. 79 

remove any precipitate which may have appeared. The 
subsequent sterilization in the test-tubes will then cause no 
precipitation. 

In rilling the test-tubes it is customary to fill some tubes 
to a depth of about 3 cm. and others to a depth of about 5 
cm. After the complete sterilization of the medium in the 
tubes as described on page 87, the first-mentioned tubes are 
placed on their sides with their mouths slightly elevated 
while the medium is still fluid, so as to form, after solidification, 
a slanting surface extending from near the bottom of one 
side of the tube to about half the length of the tube on the 
opposite side. The solidification of the agar-agar takes place 
in a short time, and as soon as it occurs the tubes are ready 
for use, this form of culture being known as a " slant " tube 
or culture (Fig. 17, b). It is well, however, to allow the 
tubes to remain in their slanting position for a day or two to 
permit the medium to become more or less adherent to the 
walls of the tube, and thus avoid its tendency to slide down- 
ward when the tubes are placed in the upright position. 

The tubes filled to a depth of 5 cm. are to be allowed to 
cool and solidfy while in an upright position, and the form 
of culture-tube thus obtained is called a " stab " culture (Fig. 
17, a), because the medium in the tube is inoculated for cul- 
ture purposes by inserting an infected platinum wire into its 
depths. 

Glucose Agar-agar. — Formula for 1000 c.c. : 

Glucose (dry), 10 grams ; 

Agar-agar, 15 

Lean beef, 500 " 

Or extract of beef, 3 

Pepton, 10 " 

Sodium chlorid, 5 " 

Water, 1000 c.c. 

This medium diners from plain agar-agar only in the addi- 
tion of 10 grams (1 per cent.) of glucose. The glucose 
should be obtained in the form of solid masses, not as a thick 
fluid, and it is to be added with the pepton and sodium 



80 PATHOLOGICAL TECHNIQUE. 

chlorid. In short, glucose agar-agar is made with glucose 
bouillon in identically the same manner that plain agar-agar 
is made with plain bouillon. 

Lactose- litmus agar-agar consists of plain agar-agar to which 
has been added 2 or 3 per cent, of lactose and sufficient litmus 
tincture to give it a pale-blue color. 

Glycerin Agar-agar. — Formula for 1000 c.c. : 



Glycerin, c. p., 


60 c.c. ; 


Agar-agar, 


15 " 


Lean beef, 


500 grams ; 


Or extract of beef, 


3 " 


Pepton, 


10 " 


Sodium chlorid, 


5 " 


Water, 


IOOO c.c. 



This medium is prepared by adding to plain agar-agar after 
its final filtration, and before running it into the test-tubes, 60 
c.c. (6 per cent.) of glycerin c. p., and mixing thoroughly. 
Gelatin (plain). — Formula for 1000 c.c: 

Gelatin, 1 00 grams ; 

Lean beef, 500 " 

Or extract of beef, 3 

Pepton, 10 " 

Sodium chlorid, 5 " 

Water, 1 000 c.c. 

Gelatin is essentially bouillon in which gelatin has been 
dissolved, so that a transparent jelly is produced which is 
solid at ordinary temperatures and fluid when slightly 
warmed. To prepare one liter, 100 grams (10 per cent.) 
of golden seal French gelatin are dissolved in a liter of the 
hot bouillon which has been heated to boiling in a saucepan. 
When the gelatin is thoroughly dissolved the mixture is 
boiled for about five minutes, and the marked acidity of the 
gelatin then carefully neutralized by the addition of caustic 
soda, in 10 per cent, solution, to a very faint alkalinity, as 
has been described in the preparation of bouillon. As in 
the case of agar-agar, the mass is then cooled to 6o° C, an 



BACTERIOLOGICAL EXAMINATIONS. 8 1 

egg beaten into it, then gently heated again to boiling, and 
boiled about ten minutes, when it is to be filtered through a 
wet folded filter into a flask. Gelatin usually filters fairly 
rapidly, but time may be saved by using two filters at once. 
When filtered it is to be run into test-tubes and sterilized, 
as described on page 87. It is used both in the form of 
"slant" and "stab" cultures, as in the case of agar-agar 
(see page 79). 

In the preparation of this medium it is important to sub- 
ject it as little as possible to the boiling temperature, for 
prolonged exposure to this destroys its power of solidifying. 
Therefore in sterilizing, gelatin tubes should never be allowed 
to remain exposed to live steam longer than twenty minutes. 
It is also important to apply the heat slowly during the pro- 
cess of heating after the addition of the egg above mentioned, 
in order to avoid "burning." 

Glucose Gelatin. — Formula for 1000 c.c. : 



Glucose, 


10 grams; 


Gelatin, 


100 " 


Lean beef, 


500 


Or extract of beef, 


3 " 


Pepton, 


10 


Sodium chlorid, 


5 " 


Water, 


1000 c.cm. 



This medium is essentially gelatin dissolved in glucose 
bouillon (see page 76), and is prepared in the same manner 
as the plain gelatin, except that glucose bouillon is used in- 
stead of plain bouillon. 

Blood-serum (Loffler's Mixture).— Formula : 

Glucose bouillon (see page 76), 1 part ; 
Beef blood-serum, 3 parts. 

This culture-medium consists of a mixture of the blood- 
serum of the bullock and glucose bouillon, which is run 
into test-tubes and coagulated by heat in such a way as to 
form a slanting surface for culture purposes — -i. e. it is used 
in the form of " slants." 



82 PATHOLOGICAL TECHNIQUE. 

The blood-serum is collected at the slaughter-house in 
tall glass jars of the capacity of a gallon or more. These 
jars should be thoroughly clean, but sterilization is not 
necessary. 

The blood which is obtained by the Jewish method of 
slaughter-— viz. by severing the carotid artery — is the best for 
the purpose, because it clots more readily. As the blood 
runs from the vessels of the animal it is received in the glass 
jar, and immediately placed in a cool place for twenty-four 
to forty-eight hours to allow it to clot and the serum to 
separate. All unnecessary agitation of the fresh blood 
should be avoided, as this interferes with its proper clotting. 
It is well to inspect the blood after a few hours, and gently 
loosen with a clean glass rod any adhesions which the clot 
may have formed to the wall of the jar, thus allowing the 
clot to more readily contract and squeeze out the serum 
from its meshes. After about twenty-four hours the serum 
is removed by the aid of a clean pipette and brought to the 
laboratory. If the clot is in good condition, more serum will 
appear after another twenty-four hours, and if necessary this 
also may be used. 

The presence of red blood-corpuscles in the serum is of 
little importance. Three parts of the beef blood-serum thus 
obtained are to be thoroughly mixed with one part of glucose 
bouillon (vide supra), convenient quantities being 900 c.c. of 
blood-serum and 300 c.c. of glucose bouillon. 

This mixture is then run into test-tubes as described on 
page 86. The quantity run into each test-tube should be 
sufficient to fill it to a depth of about 3-4 cm. The tubes 
containing the requisite amount of the mixture are next 
subjected to the action of heat while in a slanting posi- 
tion, so that the mixture in the tubes may become solid 
or coagulated, and so offer a smooth slanting surface for 
culture purposes extending from a point near the bot- 
tom of the tube to about halfway up the opposite side or 
higher. 

The coagulation is effected either in the hot-air sterilizer 
by packing the tubes on their sides, the proper slant being 



BACTERIOLOGICAL EXAMINATIONS. 83 

secured by means of strips of cardboard placed between the 
layers of tubes, or, better, in the blood-serum coagulator 
described on page 70, the tubes being arranged in several 
layers upon the shelves of the apparatus. 

If the hot-air sterilizer is employed, the temperature should 
not exceed 90 C. nor fall below 85 ° C, and the door should 
be kept closed. It is optional whether the sterilizer be 
packed full of tubes or only a few layers of tubes be coagu- 
lated at a time, with careful watching to avoid overheating. 
In the former case two or three hours will be required to 
firmly coagulate the tubes in the middle layers, while the 
lower layers may be overheated. To avoid this overheating 
of the lower layers, a false bottom or one or two layers of 
empty tubes may be employed. 

The blood-serum coagulator is much more convenient 
and gives much more satisfactory results. The temperature 
of the interior should be kept at about 95 ° C. 

To save time in heating, the apparatus may be filled with 
hot water from the hot-water faucet, if this be at hand, and 
with the aid of two Bunsen burners or a gas stove the 
proper temperature can soon be obtained. For thorough 
coagulation of all the tubes, when the apparatus is filled, 
about three hours' exposure to the temperature of the inte- 
rior is necessary. 

Whichever apparatus is employed for coagulation, it is of 
the utmost importance that the coagulation of the mixture 
be a thorough one, and that the medium in the tubes becomes 
firm and solid, otherwise bubbles and cavities will form in it 
and destroy its smooth surface when it is subjected to the 
subsequent steam sterilization. When the tubes are firmly 
coagulated they are to be packed with the cotton stopper 
uppermost in a round wire basket and sterilized by steam 
three times, as indicated on page 87, after which they are 
ready for use. 

This method of preparing blood-serum tubes is very 
different from the one usually described, a most tedious 
and time-consuming procedure, requiring a high degree 
of technical skill, by which it is practically impossible 



84 PATHOLOGICAL TECHNIQUE. 

to make use of blood-serum tubes for ordinary pur- 
poses. 

With the method here detailed we think that the best cul- 
ture-medium for the routine examination of pathological 
material is obtained. It is preferred by us for various 
reasons, chief of which are as follows : 

First, the ease and facility with which it can be prepared, 
especially when a proper coagulating apparatus is available. 

Secondly, the greater and more rapid growth of certain 
important pathogenic bacteria upon it than upon ordinary 
media. 

In the method usually described the serum (which should be 
clear or free from blood-corpuscles) is obtained under all aseptic 
precautions, is carefully mixed with sterile glucose bouillon in the 
proportions given above, and the mixture then run into sterile 
test-tubes. During all the manipulations precautions are neces- 
sary to avoid contamination, the serum never being allowed to 
come in contact with any object which is not sterile, and exposure 
to the air during the processes of transference from one vessel to 
another avoided as much as possible. 

The" mixture now being in test-tubes, it is subjected for one 
hour on each of five successive days to a temperature of 68° to 
70 C. in a chamber provided with a water-jacket. This tem- 
perature is sufficient to kill the vegetative forms of any bacteria 
which may be in it, but does not coagulate the medium. The 
intervals between the sterilizations are for the purpose of allowing 
any spores to develop into the vegetative form and thus become 
susceptible to the destructive action of heat. 

After the fifth sterilization the medium is solidified in the tubes 
in the form of " slants " by slowly raising the temperature of the 
chamber to about 8o° C, and keeping the tubes at this tempera- 
ture for several hours. In solidifying the great object is to obtain 
a gelatin-like, fairly transparent medium and to prevent opacity. 
To attain this it is necessary to proceed very carefully with the 
heating and avoid overheating or too rapid heating, the tubes 
being inspected from time to time and removed from the chamber 
as soon as their contents have the proper consistency. When 
gelatinized the tubes are placed in the incubator for twenty-four 
hours to determine whether they are sterile, after which they are 
ready for use. 

The blood-serum medium produced by this older method is 
especially suited for the cultivation of certain pathogenic bacteria 
— for instance, the bacillus tuberculosis and the bacillus diphtherial 
— but we do not think that its superiority in this respect over the 
more readily prepared, firmly coagulated form above described is 



BACTERIOLOGICAL EXAMINA TIONS. 



85 



sufficiently marked to compensate for the great difficulties in its 
preparation. 




Litmus-milk is a form of culture-medium used for deter- 
mining certain of the physiological properties of bacteria. It 
consists of cow's milk which has been colored blue by litmus 
and containing a minimum amount of cream. A pint or so 
of strictly fresh milk is placed in a flask and steamed in the 
steam sterilizer for about half an hour. When 
it is removed it will be found that most of the 
cream has collected at the surface, and it is 
then easy to draw off the milk from the deeper 
layers with a pipette into a separate flask. To 
the milk from which most of the cream has 
been thus removed is added sufficient of an 
aqueous solution of litmus (freshly filtered) to 
give it a pale-blue color. The colored milk is 
then run into test-tubes (5 cm. deep in each 
tube) and sterilized, as indicated on page 87, 
after which it is ready for use. It is of great 
importance that the milk be fresh. If it is not, 
it may contain spore-bearing bacilli which it is 
practically impossible to kill by the steam 
sterilization. 

Potato-cultures according to Bolton. — Po- 
tatoes — preferably old ones — are first washed 
to remove all the coarser particles of soil, and 
then solid cylinders are cut out of them with 
a cork-borer or apple-corer. These cylinders 
should be of a suitable diameter to fit into the 
test-tubes used for other culture-media, and 
should be about 5 cm. long. They are then 
cut longitudinally in an oblique direction with 
a sharp knife, so that a smooth slanting surface is produced, 
beginning near one end and extending diagonally to the 
other end. The pieces of potato thus prepared are next to 
be washed in running water over night. After washing, each 
piece is placed in a test-tube, the larger end resting on the 



f^, 




Fig. 18.— Potato- 
culture. 



86 PATHOLOGICAL TECHNIQUE. 

bottom of the tube, a few drops of water being added to 
prevent drying, and then sterilized as indicated on page Sy. 
If desired, a small piece of glass rod may be placed in the 
bottom of the tube to elevate the potato above the few drops 
of water (Fig. 18). 

Dunham's Pepton Solution. — Formula for iooo c.c. : 



Pepton, 


io grams 


Sodium chlorid, 


5 " 


Distilled water, 


IOOO c.c. 



The pepton and sodium chlorid are dissolved by boiling and 
the mixture filtered. The clear filtrate is then run into test- 
tubes, each test-tube being filled to a depth of 5 cm., and is 
to be sterilized as indicated on page 87, after which it is 
ready for use. 

The filling of the test-tubes with the fluid culture- 
media described in this section is best effected by means of 
a funnel of a capacity of - about a liter. In this the fluid me- 
dium is placed, and by means of a pinch-cock the requisite 
quantity of medium is run into each test-tube. In running 
the medium into the test-tubes the left hand holds the test- 
tube while the right hand removes the cotton stopper and 
manipulates the pinch-cock (Fig. 19). Care should be exer- 
cised not to allow any of the medium to come in contact with 
the neck of the test-tube, for it will make the cotton stopper 
stick to the walls of the tube. To avoid this, the delivery- 
tube of the apparatus should be inserted some distance into 
the test-tube in filling. 

The quantity of culture-medium run into each test-tube 
varies according to -the form of culture desired and the cha- 
racter of the medium. In the case of liquid media and solid 
media designed to be used in the form of " stab " cultures the 
tubes should be filled to a depth of 5 cm. For " slant " cul- 
tures of solid media a depth of about 3 cm. is sufficient, or 
enough to give a slanting surface from the bottom of the 
tube to about halfway up the opposite side. 

Small Ehrlenmeyer flasks are sometimes used for bouillon 



BA CTERIOL O GICAL EX A MI N A TIONS. 



87 



cultures. These are of about 100 c.c. capacity, and are filled 
to a depth of about 1 cm. with the medium. The necks are 




Fig. 19. — Method of filling test-tubes with culture-medium (Warren). 

provided with cotton stoppers, and the whole sterilized and 
treated as test-tube cultures. 



STERILIZATION OF CULTURE=HEDIA. 

In general, the sterilization of culture-media is effected by 
allowing them to remain exposed to the action of live steam 
in the steam sterilizer for twenty to forty-five minutes 011 
three successive days. The period of exposure to live steam 
varies somewhat with the kind of culture-medium. A single 
exposure for the time mentioned is sufficient to destroy all 
bacteria present in what is called the vegetative or non-re- 
sistant form, but it will not kill spores, which represent a 



88 PATHOLOGICAL TECHNIQUE. 

stage in the life-history of certain bacteria, in which form the 
organism is highly resistant to sterilizing agents. 

Under favorable conditions, such as are to be found in 
culture-media at ordinary room-temperature, these spores 
develop into the vegetative or non-resistant form, which 
are easily destroyed by heat. Therefore, in order that 
the culture-medium be made sterile, it is necessary that it be 
again subjected to the action of steam on the following day 
for the same length of time, when the vegetative forms of 
the few surviving spores will have developed, and will be 
capable of destruction by ordinary exposure to live steam. 

As a further precaution a third similar sterilization on the 
next day is necessary. Therefore, three steam sterilizations, of 
from twenty minutes to -one hour each, on successive days, are 
required to keep culture-media sterile for an indefinite period. 

A freshly prepared culture-medium must be sterilized on 
the same day that it is prepared, or by the next day it may 
be found to contain living bacteria, especially if kept over 
night in a warm room. 

For the purpose of sterilization the test-tubes containing 
the media are to be placed in a round wire basket which fits 
into the steam sterilizer, thus facilitating the handling of the 
tubes and also keeping them upright. 

If the medium be in a flask ready for running into test- 
tubes, and if it be not convenient to do this the same day, 
the medium may be preserved as long as desired by insert- 
ing a cotton stopper into the mouth of the flask and then 
sterilizing as above indicated. 

The time of each sterilization for bouillon, agar-agar, 
blood-serum, etc. may be fixed at half an hour ; for potato- 
culture tubes and for litmus-milk, forty-five minutes. 

In the case of gelatin, however, the time of exposure to 
live steam should be shorter, owing to the danger of destroy- 
ing the solidifying power of the medium by too much heat- 
ing. Twenty minutes' exposure is sufficient. 

Large quantities of culture-media contained in flasks 
should be sterilized for forty-five minutes to an hour, for 
obvious reasons. 



BACTERIOLOGICAL EXAMINATIONS. 89 

III. BACTERIOLOGICAL EXAMINATIONS AT 
AUTOPSIES. 

The aim of the bacteriological examination at an autopsy 
is to determine whether bacteria are present or not in the 
tissues, and, if present, to ascertain not only their species, 
but also the extent and comparative numbers of their dis- 
tribution throughout the principal internal organs. 

This is accomplished chiefly by means of two methods of 
examination — viz. the direct examination with the microscope 
of cover-glass preparations, and the results of cultures made 
from the tissues. Both of these methods should be em- 
ployed together, but the culture method is perhaps the most 
important. A third but less frequent method is the inocula- 
tion of animals with pieces of tissue or material taken from 
the body. 

Cover-glass Preparations. — The method of demon- 
strating the presence of bacteria in pathological material by 
means of cover-glass preparations depends upon the fact 
that bacteria have the property of being colored by certain 
of the aniline dyes, and thus may be more readily seen by 
the microscope, The cover-glasses are best kept in alcohol, 
and as required for use wiped dry with a soft cotton cloth. 
A cover-glass preparation is made as follows : A very small 
amount of tissue or material to be examined is thinly spread 
over the surface of a clean thin cover-glass, so as to give a 
streaked appearance to the surface, but not a definite layer, 
which is ordinarily too thick for satisfactory examination. 
The charged cover-glass is then dried by holding it in the 
fingers over the flame of a Bunsen burner, and when dry it 
is placed, charged surface uppermost, in the grasp of a pair 
of Cornet forceps, by means of which it is passed rapidly 
three times through the flame of a Bunsen burner or alcohol 
lamp. This " fixes " the material on the glass, and the 
preparation is then ready for staining by one of the various 
methods given below. In staining, the cover-glass is held 
by means of Cornet forceps with the charged side upper- 
most and level, and the surface is then completely covered 



90 PATHOLOGICAL TECHNIQUE, 

with the staining fluid, which is poured upon it from a drop- 
ping-bottle. It may then be heated over the flame of the 
Bunsen burner, washed in water, and submitted to any further 
manipulation which may be necessary while still in the grasp 
of the forceps. When the staining is completed the prepara- 
tion is next to be prepared for microscopic examination. 
This is done by placing the cover-glass, with as much water 
as will adhere to it, charged side downward, on a " slide," 
and then removing all remaining water, except a thin film of 
water between the slide and cover-glass, by gentle pressure 
with several thicknesses of filter-paper. The preparation is 
then ready for examination with an oil-immersion lens. The 
presence of this film of water is very essential for a satis- 
factory examination with the microscope, and its evaporation 
may be compensated for by a drop of water placed at the 
edge of the cover-glass. The preparation may also be 
mounted in balsam after carefully drying it first between 
filter-paper and then holding it in the fingers over the Bun- 
sen flame, but the examination in water mount is better, 
because the apparent size of the bacteria is greater in this 
than when mounted in balsam. 

It is of the greatest importance that cover-glass prepara- 
tions be made from all exudates or acute inflammatory con- 
ditions of organs or tissues, so that the results of cultures 
can be controlled and some idea formed of the number and 
character of the bacteria present. They are of especial use 
as enabling one sometimes to recognize the presence of an 
organism which does not grow in the culture for some 
reason, and whose presence might escape notice, while their 
importance in many cases in the identification of the pneu- 
mococcus and the bacillus tuberculosis must be apparent. 
In certain cases it is best to examine the material in its 
natural state and without drying and staining. This is espe- 
cially true of suspected infections with actinomyces and the 
amebae coli. In these cases the material should be spread 
over a cover-glass, and this placed, while the material is still 
moist, charged surface downward, on a " slide," and then 
examined with various powers of the microscope. If neces- 



BACTERIOLOGICAL EXAMINATIONS. 9 1 

sary, a small amount of normal salt solution (0.6 per cent.) 
may be added to dilute the material and facilitate the ex- 
amination. 
Staining Methods for Cover-glass Preparations. — 

Simple staining" is used for the demonstration of bacteria in 
general, and also useful in gaining an idea of the character 
of the cellular elements in the preparation. 

LofHer's alkaline methylene-blue solution is perhaps the 
best staining fluid to use for simple staining, for it does not 
stain so diffusely and intensely as do the other commonly 
used dyes, such as fuchsin and gentian violet, which may 
also be employed. 

The cover-glass, covered with the staining fluid, should be 
warmed over the Bunsen flame, so that the fluid steams, for 
about fifteen seconds. Boiling should be avoided. The 
preparation is then washed in water for two or three seconds 
and mounted. 

Gram's Method of Staining". — 1. Cover the preparation 
with aniline-gentian-violet solution for thirty seconds. 

2. Wash in water for two or three seconds. 

3. Cover the preparation with Gram's solution of iodin 
for thirty seconds. 

4. Wash with 95 per cent, alcohol until the color ceases 
to come out of the preparation. 

5. Wash in water for two or three seconds and mount. 
Certain bacteria are stained by this method, while others 

are not. Bacteria when stained by it appear dark blue or 
black, while the nuclei of the cells are rather faintly stained 
or not stained at all. The method is especially useful in the 
demonstration of bacteria which are stained by it when 
they are present in small numbers or when a few Gram- 
staining bacteria are mixed among numbers of bacteria 
which do not stain by this method. It also has some value 
as a means of differentiating between bacteria which may be 
very much alike in size and shape. 

In the following table the behavior of the more important 
pathogenic bacteria toward the method of Gram is indi- 
cated : 



92 PATHOLOGICAL TECHNIQUE. 



Stained by Gram's Method. 
Staphylococcus pyogenes aureus. 
Staphylococcus pyogenes albus. 
Streptococcus pyogenes. 
Pneumococcus. 
Micrococcus tetragenus. 
Bacillus diphtherise. 
Bacillus tuberculosis. 
Bacillus of anthrax. 
Bacillus of tetanus. 
Bacillus aerogenes capsulatus. 



Decolorized by Gram's Method. 
Gonococcus. 

Diplococcus intra-cellularis meningi- 
tidis. 
Typhoid bacillus. 
Bacillus coli communis. 
Spirillum of Asiatic cholera. 
Bacillus pyocyaneus. 
Bacillus of influenza. 
Bacillus of glanders. 
Bacillus proteus. 
Bacillus mucosus capsulatus. 
Bacillus of malignant edema. 



Stain for the Bacillus Tuberculosis (Gabbet's Method). 
— I. Stain in carbol-fuchsin solution for one minute, steaming 
the preparation, and adding more staining fluid as it evapor- 
ates. The surface of the cover-glass is to be kept com- 
pletely covered with the staining fluid during the heating 
to avoid precipitation. 

2. Wash in water for two or three seconds. 

3. Cover with Gabbet's methylene-blue solution for about 
thirty seconds. The uncharged surface of the cover-glass 
should be cleansed at the same time from any dried stain by 
running over it a few drops of the same solution. 

4. Wash in water thoroughly and mount. 

In this way the bacillus tuberculosis is stained red, while 
other bacteria and the nuclei of cells are stained blue. 

This method, as well as many others, depends upon the 
fact that the bacillus tuberculosis, when once thoroughly 
stained with an aniline dye, does not give up its stain in the 
presence of acids, as nearly all other bacteria do. The ba- 
cillus tuberculosis may therefore be identified even among a 
mixture of other bacteria by this property, taken in connec- 
tion with its morphology, in most of the routine work of the 
pathological laboratory. Practically, the only other bacilli 
with which it may be confounded are the bacillus of leprosy 
and the smegma bacillus, both of which, when stained, re- 
sist the decolorizing action of acid. It may be differentiated 
from the smegma bacillus by the fact that it is not decolor- 
ized by alcohol (95 per cent.) after the usual treatment with 



BACTERIOLOGICAL EXAMINATIONS. 93 

acid, while the smegma bacillus is decolorized under these 
circumstances. The preparation may be washed in alcohol 
for about thirty seconds. 

As a rule, the differential test with alcohol need only be 
applied in the examination of urine and the material derived 
from about the external genitalia, especially in the case of 
females. 

The differentiation from the bacillus of leprosy by certain 
quantitative differences in staining reactions has been at- 
tempted, but it is very unsatisfactory, and it is doubtful if 
there is as yet any reliable method of distinguishing between 
these two organisms, considered by themselves. The great 
rarity of leprosy in this country, however, renders confusion 
with the organism found in that disease very improbable. 

Welch's Method of Staining- the Capsule of the Pneu- 
mococcus. — This method depends upon the fact that acetic 
acid precipitates the mucin-like substance of which the cap- 
sule is composed, and that the precipitated material of the 
capsule is not soluble in a 2 per cent, solution of sodium 
chlorid. Therefore, any necessary washing of the prepara- 
tion is to be done in the solution of sodium chlorid, and the 
mount is to be made in the same solution or in balsam. 

The method is as follows : 

1. Cover the preparation with glacial acetic acid for a few 
seconds. 

2. Drain off and replace (without washing in water) with 
aniline-gentian-violet solution. The staining solution is to 
be repeatedly added to the surface of the cover-glass until 
all of the acid is replaced. 

3. Wash in 2 per cent, solution of sodium chlorid and 
mount in the same. 

Curry's Method of Staining* the Capsule of the Pneu- 
mococcus. — 1. Cover the preparation with glacial acetic 
acid for a few seconds. 

2. Wash off the acetic acid with a 1 per cent, solution of 
potassium hydroxid. 

3. Stain with aniline-gentian-violet for one minute, with- 
out previously washing off the hydroxid. 



94 PATHOLOGICAL TECHNIQUE. 

4. Wash quickly in water. 

5. Dry thoroughly and mount. 

If the specimen is stained too deeply, the capsule may 
be slightly decolorized by washing for a few seconds in a 
0.5 per cent, solution of acetic acid and then drying thor- 
oughly. It is important that the specimen be quite dry 
when mounted, as the xylol tends to decolorize the capsules 
when moisture is present. 

This method has been in use in the Pathological Laboratory of 
the Boston City Hospital, where it was originated, and has been 
found to work very satisfactorily. 

The capsule may also be demonstrated by Gram's method (see 
page 90) if the decolorization with alcohol be not pushed too far. 
In this case the capsule will be outlined around the deeply stained 
organism as a broad clear zone bounded by a dark line. 

Examination by Cultures. — The demonstration of the 
presence of bacteria in a tissue or exudate by means of cul- 
tures consists in bringing a small amount of the material to 
be examined in contact with some solid nutrient substance 
in which the bacteria will thrive. On this the bacteria by 
multiplication form masses or colonies visible to the naked 
eye, and present appearances which enable a practised eye 
in many cases to recognize the species of the bacteria of 
which they are composed. Of the solid culture-media de- 
scribed in the preceding section, the coagulated blood-serum 
is distinctly the best to use for the demonstration of the 
presence of bacteria in routine pathological work, because 
certain of the most important pathogenic bacteria grow bet- 
ter upon it than upon agar-agar or similar media. The other 
media have important uses in the study of the bacteria after 
their isolation from the tissues, as is pointed out elsewhere. 
The blood-serum medium here described has been found en- 
tirely suitable for the isolation of the bacillus tuberculosis 
from tubercular lesions, which proves its efficiency as a cul- 
ture-medium. 

Method of Preparing" Cultures on Blood-serum. — The 
preparation of cultures on the coagulated blood-serum con- 
sists in distributing over the surface of the medium in a test- 



BACTERIOLOGICAL EXAMINATIONS. 9$ 

tube as much of the tissue or other material as will adhere 
to the end of a piece of stiff platinum wire hammered flat 
at the end. The wire is fixed in the end of a glass or metal 
rod, and should be about 8 cm. long. It should have a 
rounded spatula-like extremity, and should be thick enough 
not to bend easily. 

It is, of course, essential that the material brought in con- 
tact with the culture-medium should be free from bacteria 
not originally present in it, or that it be not contaminated 
with bacteria from outside sources. Therefore, in taking 
material from the interior of organs and tissues the surface 
is first sterilized by searing it with a hot knife, such as an ordi- 
nary case-knife, which has been heated in the Bunsen flame, 
and then, through a small incision made with another hot 
knife in this seared or sterilized area, the material from the 
interior is collected on the end of the platinum wire, which 
has also been previously heated in the Bunsen flame to 
sterilize it, and then cooled either by plunging it in the 
water of condensation of the culture-tube for a few seconds 
or by moving it about in the interior of the tissue. 

In the case of exudations on free surfaces, however, this 
searing is impossible, and therefore care should be exercised 
at the autopsy not to contaminate any such exudate by 
handling before the material for culture has been obtained 
with the platinum wire. The material thus secured is then 
transferred by means of the platinum wire to the surface of 
a blood-serum culture-tube, and the infected wire gently 
rubbed over all of the surface of the culture-medium, avoid- 
ing, however, the breaking of the surface. It is important 
that the material be well distributed over the nutrient surface. 
If the material is suspected of containing a large number of 
bacteria, as in the case of suppurations or acute inflamma- 
tory lesions, a second tube should be inoculated from the 
first one by touching the platinum wire, previously sterilized 
and cooled, to the infected surface of the first tube, and then 
gently rubbing the infected wire over the surface of the 
second tube. This operation is called " diluting." The 
object of this is to obtain, after the development of the cul- 



g6 PATHOLOGICAL TECHNIQUE. 

ture, a sufficiently small number of colonies in the second 
tube, so that they may be discrete — i. e. separated from one 
another — and thus be enabled to exhibit their characteristic 
appearances, which are largely lost when the colonies are so 
numerous as to be confluent. 

If thought desirable, a third tube may be similarly inocu- 
lated from the second, but this is rarely necessary. In mak- 
ing these " dilutions "it is well to cool the platinum wire in 
the water of condensation of the sterile tube before touch- 
ing it to the infected surface of the other tube. As a rule, 
one tube will be sufficient to obtain discrete colonies from 
organs or tissues in which no suppurative or exudative con- 
dition is present. 

After the manner above indicated cultures are to be made 
at the autopsy as a matter of routine from the blood of the 
heart, from the liver, the spleen, the lung, and the kidney. 
Cultures are also to be made from any acute inflammatory 
lesion in any situation. 

As each culture-tube is infected it is to be labelled with 
the name of the organ or of the material from which it was 
infected, and with the date. For this purpose small paper 
labels coated with mucilage are used. 

The culture from the blood of the heart should be made 
before the removal of that organ from the body, by searing 
the right ventricle and then puncturing it with a sterilized 
knife to admit the platinum wire. The amount of blood 
used for the culture should be as much as will adhere to the 
platinum wire. Cultures from vegetations in acute endo- 
carditis are not usually of much value unless they are suf- 
ficiently large to enable a sterilization of their surface to be 
effected and material for culture secured from their interior. 

All cultures are to be placed, as soon as made, in the in- 
cubator or thermostat, where they are conveniently kept in 
small tin cups. 

The inoculation of animals at an autopsy is mainly useful 
in determining the presence of the pneumococcus or the 
bacillus tuberculosis when the ordinary methods are con- 
sidered inadequate. 



BACTERIOLOGICAL EXAMINATIONS. 97 

For determining with fair certainty whether the pneinno- 
cocciis is present or not, a small portion of the suspected 
material is inserted beneath the skin of a brown or white 
mouse at the root of the tail by means of the platinum 
wire (see page 72). If the organism is present, the animal 
will usually die in about twenty-four hours, and on micro- 
scopic examination of cover-slip preparations of its blood 
and organs the characteristic encapsulated lanceolate diplo- 
cocci will be found (see page 129). 

The presence of the bacillus tuberculosis may be deter- 
mined by inoculating a guinea-pig subcutaneously with some 
of the suspected material. A rabbit may also be used for 
this purpose. The material selected for inoculation should 
not be larger than a pea. 

If infection with the bacillus tuberculosis has occurred, 
after about three weeks the inguinal lymph-glands will be 
found enlarged and shot-like to the touch, and later the 
animal emaciates, with increase in the glandular enlargement. 
Death follows after a variable length of time, rarely under 
two months. At the autopsy the lesions of miliary tuber- 
culosis will usually be found in the spleen and liver, while 
the inguinal lymph-glands and the retroperitoneal glands 
will be enlarged and more or less caseous. In this caseous 
material the bacillus tuberculosis should be demonstrated to 
make the examination complete. 

The diagnosis of tuberculosis in the animal may be estab- 
lished after three or four weeks if the enlarged inguinal 
lymph-glands, removed under ether anesthesia, show the 
histological signs of tuberculosis or contain tubercle bacilli 
on microscopic examination. The subcutaneous inoculation 
in the abdominal wall is to be preferred to intraperitoneal in- 
oculation, not only for the reason that the diagnosis may be 
more quickly made from the condition of the inguinal glands, 
as above indicated, but also because there is no danger of 
rapid death of the animal from acute peritonitis — a result 
which may follow inoculation into the peritoneal cavity with 
suspected material containing other bacteria. 



98 PATHOLOGICAL TECHNIQUE. 

IV. THE METHODS OF STUDYING BACTERIA IN 
CULTURES. 

The cultures made at the autopsy, as described in the last 
section, having been in the incubator for eighteen to twenty- 
four hours, are next to be studied, and the identity or diag- 
nosis of the bacteria whose colonies have grown out upon 
them is to be established. The identification of the infecting 
bacteria present in most cases may be made from a con- 
sideration of the size, color, and general appearance of the 
colonies as they appear on the surface of the blood-serum 
when taken in connection with the morphology of the bac- 
teria composing them. In some cases, however, this may 
not be -sufficient evidence upon which to base the diagnosis, 
and it may be necessary to obtain further facts in regard to 
a given organism in order to identify it with a sufficient 
degree of certainty. Thus it may be necessary to observe 
the appearances of its growth in pure culture in various 
media, and to ascertain whether it produces certain chemi- 
cal changes in the media by its growth. Its ability to grow 
with or without oxygen, its reaction toward staining agents, 
whether it has independent motion or not, and its effects 
upon animals by inoculation, are also points which may 
have to be determined to enable one to make a positive diag- 
nosis of the species to which the organism belongs. There- 
fore, in the study of the colonies of the bacteria which 
have developed in the cultures a familiarity with certain 
fundamental bacteriological methods is necessary. These 
will be described in this section. 

1. COVER=GLASS PREPARATIONS FROM CULTURES. 

A minute proportion of a colony or bacterial growth, the 
component organisms of which are to be examined, is picked 
up on the end of the platinum wire, which has been pre- 
viously heated in the Bunsen flame and cooled, and is thinly 
distributed on the surface of a cover-glass by gentle move- 
ments of the platinum wire. It is very important that the 
bacteria should be more or less separated from one another 



BACTERIOLOGICAL EXAMINATIONS. 99 

in places, so that a good view of the individual organisms 
may be obtained. This can often best be effected by placing 
a minute drop of water on the cover-glass first, and then 
moving the infected end of the platinum wire back and forth 
through this. The preparation is then dried between the 
fingers over the Bunsen flame, and next, having been 
grasped with the Cornet forceps, is to be rapidly passed three 
times through the Bunsen flame. While still held by the 
forceps, it is then stained by covering it from a dropping- 
bottle with the staining solution, and washed in water or 
submitted to any other manipulation which may be required. 
The staining solutions ordinarily employed are carbolic- 
fuchsin, aniline-gentian-violet, and methylene-blue. If methy- 
lene-blue be used, it is best to steam the preparation in 
staining for about ten seconds, but in the case of the 
other stains this is not necessary, for they stain deeply almost 
immediately, so that the staining solution need not remain 
longer in contact with the bacteria than a few seconds. 
After staining the cover-glass is to be washed in water and 
mounted for examination, as described on page 89 in the 
case of cover-glass preparations from tissues. 

Gram's method of staining may also be used for cover-glass 
preparations from cultures. As has been pointed out elsewhere 
(see page 91), this method does not stain all species of bacteria, 
but some species are stained by it and others are not. This fact 
is sometimes useful in aiding in the identification of a given 
organism, and as enabling one to recognize the presence of a few 
Gram-staining bacteria among a large number of others which are 
unstained. 

The method as applied to cover-glass preparations from cultures 
is as follows : 

1. Stain in aniline-gentian-violet, without steaming, for thirty 
seconds. 

2. Wash in water three seconds. 

3. Cover with Gram's solution of iodin for thirty seconds. 

4. Wash in water three seconds. 

5. Wash in 95 per cent, alcohol until the color ceases to come 
out of the preparation. 

6. Wash in water three seconds. 

7. Mount. 

Bacteria stained by this method have a blue-black color. 

For a list of bacteria that stain by Gram's method see page 92. 



100 PATHOLOGICAL TECHNIQUE. 

The Staining" of Spores. — Spores take up the anilin dyes 
with difficulty, probably owing to their dense protective envelope. 
When once stained, however, they do not give up their color 
easily, and resist decolorizing agents. The cover-glass prepara- 
tions should be thinly spread. 

Abbott' 's Method. — i. Stain the cover-glass preparation deeply 
with methylene-blue, heating repeatedly until the staining solu- 
tion boils, but do not boil continuously, during about one minute. 

2. Wash in water. 

3. Wash in 95 per cent, alcohol containing 0.2 to 0.3 per cent, 
hydrochloric acid. 

4. Wash in water. 

5. Stain for eight to ten seconds in aniline-fuchsin solution. 

6. Wash in water and mount. 

The spores are stained blue and the bodies of the bacteria red. 
Moeller's Method. — 1. Wash the cover-glass preparation in 
chloroform for two minutes. 

2. Wash in water. 

3. Treat with 5 per cent, solution of chromic acid one-half to 
two minutes. 

4. Wash in water. 

5. Stain with carbol-fuchsin, heating slowly until the fluid boils. 

6. Decolorize well in a 5 per cent, solution of sulphuric acid. 
7i Wash in water. 

8. Stain in aqueous solution of methylene-blue (1 gram to 100 
c.c.) thirty seconds. The spores will be red, the bodies of the 
bacteria blue. 

The preliminary treatment with chloroform is to cleanse the 
preparation. 

Fiocca suggests the following rapid method: "About 20 c.c. 
of a 10 per cent, solution of ammonia are poured into a watch- 
glass, and ten to twenty drops of a saturated aqueous solution of 
gentian-violet, fuchsin, methylene-blue, or safranin added. The 
solution is warmed until vapor begins to rise, then is ready for 
use. A very thinly-spread cover-glass, carefully dried and fixed, 
is immersed for three to five minutes (sometimes ten to twenty 
minutes), washed in water, washed momentarily in a 20 per cent, 
solution of nitric or sulphuric acid, washed again in water, then 
counterstained with a watery solution of vesuvin, chrysoidin, 
methylene-blue, malachite-green, or safranin, according to the 
color of the preceding stain. This whole process is said to take 
only from eight to ten minutes, and to give remarkably clear and 
beautiful pictures." 

The Staining of Flagella. — All motile bacteria are 
provided with delicate wavy, hair-like prolongations of their 
protoplasm, called flagella, which are of comparatively great 
length. These flagella are the locomotor organs of the 



BACTERIOLOGICAL EXAMINATIONS. IOI 

organism. The number of them attached to each individual 
varies to a considerable extent with the species of the bac- 
teria. Thus the individuals of some species have but one 
flagellum, while the individuals of other species may have 
few or many springing from all parts of the organism. 

The flagella are not rendered visible by the ordinary 
methods of staining, but special methods are necessary for 
their demonstration. These methods depend essentially upon 
the use of a mordant, which causes the flagella to take up 
the stain. 

The cover-glasses must be absolutely free from grease in 
these methods, so that the watery fluids may be spread 
evenly over them and not run into patches. The cover- 
glasses may be prepared by warming them in concentrated 
sulphuric acid for a time, washing them in water, and keep- 
ing them in a mixture of equal parts of alcohol and strong 
ammonium hydroxid solution. 

When used they are to be dried on a cloth which has pre- 
viously been soaked in ether and allowed to dry, in order 
that it may contain no trace of fat. Another way to treat 
the cover-glasses is to take them from alcohol, dry them 
with a clean cloth, and then heat them by means of the 
Cornet forceps in the Bunsen flame to burn off any fat or 
grease. 

The bacteria must be distributed .upon the cover-glass well 
separated from one another in these methods. They should 
not be subjected to too much manipulation in doing this, for 
the flagella are readily broken up. The distribution of the 
bacteria upon the cover-glass is effected as follows : 

Upon each of three or four cover-glasses, free from grease, 
a small drop of water is placed by means of the platinum 
wire. A minute portion of the bacterial growth is then 
secured in the end of the platinum wire and gently mixed 
with a drop of water on one of the cover-glasses. Then a 
small portion of the suspension is transferred to the drop of 
water on the second cover-glass with the wire, and likewise 
spread on this cover-glass. In a similar manner the third 
cover-glass is prepared from the second. 



102 PATHOLOGICAL TECHNIQUE. 

Another way is to place two drops of water on a cover- 
glass — to draw the infected wire once through one of them 
across the surface, and then once through the other drop, 
thus making two streaks. This subjects the bacteria to less 
manipulation and gives a good distribution in places. 

The cover-glasses prepared as above indicated are to be 
allowed to dry in the air ; " fixing " them in the flame is not 
necessary. As soon as they are thoroughly dry they are 
ready to be stained by any of the methods given below. 
The cultures used for the preparations should not be older 
than eighteen to twenty-four hours. Solid culture-media, 
such as agar-agar, should be employed. 

Loffler's Method. — Treat the preparation for about one 
minute with the freshly filtered mordant solution, which is — 

Aqueous solution of tannic acid (20 grams tannic acid 

to IOO c.c. water), 10 c.c. ; 

Cold saturated solution of ferrous sulphate, 5 c.c. ; 

Saturated aqueous or alcoholic solution of gentian- 
violet or fuchsin, 1 c.c. 

The cover-glass is to be covered with this while held with 
the Cornet forceps, as in ordinary methods of staining. The 
mordant, thus placed on the cover-glass, may be gently 
heated by holding the preparation high over the flame for a 
period of about one minute, but it must not be boiled. After 
this the preparation is to be washed in water, and then 
stained with a freshly prepared and filtered solution of ani- 
line-gentian-violet or aniline-fuchsin, with gentle heating for 
thirty to sixty seconds. It is then again washed in water, 
and mounted in water or balsam for examination. 

In using this method, as well as the others, an important 
thing to avoid is overheating ; in fact, the warming of the 
mordant is not really necessary. The mordant may be 
freshly mixed every time or kept indefinitely for use. 

The ferrous sulphate solution should always be freshly 
prepared, for it rapidly decomposes. The solution of tannic 
acid keeps well, however. 

The addition of varying quantities of acids or alkalies for 



BACTERIOLOGICAL EXAMINATIONS. 103 

different species of bacteria, as recommended by Loftier, is 
not necessary. 

Pitfield's Method. — Treat the preparation with a mixture 
of equal parts of two solutions, which are as follows : 
Solution A. — Saturated aqueous solution of alum, 5 c.c. ; 
Saturated alcoholic solution of gentian- 
violet, 1 c.c. ; 
Distilled water, 5 c.c. 

Solution B. — Tannic acid, 1 gram ; 

Distilled water, 10 c.c. 

These solutions are to be made up cold, and are to be freshly 
filtered before mixing. The mixture placed on the cover- 
glass is to be gently heated, but not boiled, during about 
one minute, then washed in water and mounted. 

Precipitates occur with this method which mar the prep- 
aration, but do not necessarily obscure the flagella. If it is 
desired to avoid these, clearer but not so deeply stained 
preparations may be obtained by filtering the mixture of the 
two solutions before using, and then, after treatment with the 
filtered mixture, to stain for one minute in aniline-gentian- 
violet without boiling. 

Bunge's Method. — The mordant used consists of — 
Liquor ferri sesquichloridi diluted with distilled 

water 1 : 20, I part ; 

Saturated aqueous solution of tannic acid, 3 parts. 

This mixture improves by keeping, and is to be filtered for 
use. It gives good results after standing in a loosely stop- 
pered bottle for two or three weeks, when it has acquired a 
red-brown color and a scum on the surface. It may then be 
said to be " ripe." 

The fresh mordant artificially ripened by the addition of 
the peroxid of hydrogen gives the best results. This is done 
as follows : 

Filter the above mixture into a test-tube and add peroxid 
of hydrogen (3 per cent, solution), drop by drop, until a red- 
brown color appears. Then shake and filter immediately 
through a double filter on the cover-glass preparations. 



104 PATHOLOGICAL TECHNIQUE. 

Allow the mordant to act one minute on this ; then wash in 
water, dry off with filter-paper, and stain the preparation 
with carbol-gentian-violet, gently warming, but not boiling. 
Then wash in water and mount. The artificially ripened 
mordant is good only for a few minutes. The amount of 
peroxid necessary will be about 0.5 c.c. per 5 c.c. of mordant. 

Capsules, in addition to flagella, may also be demonstrated 
in the case of certain bacteria by treating the preparation, 
before applying the mordant and stain, with 5 to 10 per cent, 
acetic acid, and afterward decolorizing with 1 per cent, acetic 
acid. 

The procedure for the demonstration of both capsules and 
flagella may be summarized as follozvs : 

1. 5 to 10 per cent, acetic-acid solution, thirty to sixty 
seconds. 

2. Wash in water and dry with filter-paper. 

3. Apply mordant one minute, not heating or with gentle 
heat. 

4. Wash in water and dry with filter-paper. 

5. Stain with carbol-gentian-violet, warming gently for one 
minute. 

6. Wash in water and decolorize in 1 per cent, acetic acid 
solution thirty to sixty seconds. 

7. Wash in water and mount. 

Bunge recommends that the preparations be made from 
gelatin cultures two days old, rather than from cultures grown 
in the thermostat on agar-agar. 

Van Ermengem's Method. — Make a very dilute suspen- 
sion in 0.6 per cent, sodium chlorid solution of an eighteen- 
hour agar-agar culture of the organism, and place a drop of 
the suspension in the center of a thoroughly clean cover- 
glass. Allow the drop to dry in the air, and then " fix " the 
preparation by passing the cover-glass rapidly three times 
through the flame. To the " fixed " preparation apply the 
following mordant for half an hour at room-temperature or 
for five minutes at 50 to 60 ° C. : 

Osmic acid (2 per cent, solution), 1 ; 

Tannin (2 per cent, solution), 2. 



BACTERIOLOGICAL EXAMINATIONS. 105 

To this four or five drops of glacial acetic acid may be added. 
Next wash in water and in alcohol (95 per cent.), and then 
immerse for a few seconds in a 0.25 to 0.5 per cent, solution 
of silver nitrate. From this, without washing, transfer to a 
small dish containing the " reinforcing bath," which is of the 
following composition : 



Gallic acid, 


5 grams 


1 aniiin, 

Fused potassium acetate, 


3 
10 " 


Distilled water, 


350 c.c. 



In this the preparation is washed for a few seconds, and is 
then again immersed in the solution of silver nitrate (0.25 to 
0.5 per cent). The preparation is moved about in this solu- 
tion until the solution begins to acquire a brown or black 
color, when it is removed, washed thoroughly in water, dried, 
and mounted in balsam. 

2. METHODS OF OBTAINING PURE CULTURES. 

When it is desired to obtain a pure culture of bacteria, a 
colony or a portion of a colony of the organism is secured 
on the end of the sterile platinum wire, and transferred by 
this means to the culture-medium in another test-tube. The 
bacteria thus sown in the fresh culture-medium multiply 
there, and produce a growth visible to the naked eye which 
exhibits appearances more or less characteristic of the 
species. This growth, if the medium be a solid one, will 
usually be in the form of confluent colonies ; if the medium 
be a fluid one, the growth may appear as a sediment with or 
without clouding of the liquid, or it may manifest other 
peculiarities according to the species to which the organism 
belongs. If other bacteria are present in the culture from 
which it is desired to obtain material for a pure culture, it is 
important that the material should be taken from a colony 
of the organisms which is well separated from other colonies 
— i. e. that the colony should be a so-called " discrete " one. 

In transplanting, the culture-tube containing the colony 



106 PATHOLOGICAL TECHNIQUE. 

and the culture-tube that is to be infected from it are held 
side by side in the left hand in a slanting position in such a 
way as to give a good view to the operator of the surface of 
the media in each, while the cotton stoppers are removed 
and held between the fingers of the same hand (Fig. 20). 
The object of holding the tubes in a slanting position is to 
offer less chance of contamination from bacteria gaining en- 
trance to the culture-medium from the air. 

The platinum wire, which is manipulated by the right 
hand, is first sterilized by holding in the Bunsen flame until 
it glows, and then cooled by contact with the media to be 
infected, after which its free end is carefully brought in 
contact with the discrete colony Or pure culture-growth, 




Fig. 20. — Method of holding tubes during inoculation. 

and immediately inserted into the sterile tube to inoculate 
it. The manner of inoculating the 'sterile culture-medium 
in the other tube with the infected platinum wire will vary 
with the form and character of the culture desired. 

If the medium to be inoculated is a fluid one, the wire is 
simply immersed in it and moved back and forth once or 
twice. If the medium be a solid one in the form of a slant, 
the infected end of the wire is drawn over the surface once 
or twice from the bottom of the slant to its upper end ; or 
if the solid medium in the tube be arranged for a stab cul- 
ture (see page 79), the infected wire is to be plunged once 
through the center of the mass to the bottom of the tube. 
After the tubes have been inoculated as above indicated, the 
wire is to be immediately withdrawn and the cotton stoppers 
replaced. They are then to be placed in the incubator for 
development. Gelatin cultures, however, must not be so 



BACTERIOLOGICAL EXAMINATIONS. 107 

treated, but are to be kept at room-temperature, for the heat 
of the incubator would cause the gelatin to become fluid. 

These details as to the manner of manipulating the cul- 
ture-tubes, cotton stoppers, and platinum wire also apply to 
the procedure described below. 

Method of Isolation of a Bacterium in Pure Cul- 
ture from a Mixed Growth. — If there is a more or less 
confluent growth of colonies of various kinds in a culture- 
tube, and it is desired to isolate a pure culture of one of the 
species of bacteria present, it is obvious that the first step is 
to obtain separate or " discrete " colonies of that organism. 
This is accomplished by securing a minute quantity of the 
growth on the end of the sterilized platinum wire (preferably 
from a spot where the organism is prevalent), and distrib- 
uting this over the surface of a sterile blood-serum tube by 
gently rubbing the end of the infected wire as thoroughly 




Fig. 21. — Diluting cultures. 

as possible over it. The wire is then sterilized in the Bunsen 
flame, cooled in the water of condensation of a second sterile 
blood-serum tube, next touched to the infected surface of the 
first tube, and the wire thus infected gently and thoroughly 
rubbed over the surface of the second. In a similar manner a 
third tube is then infected from the second, and then all the 
tubes placed in the incubator for eighteen to twenty-four hours. 
It is evident that comparatively few bacteria will be sown on 
the medium of the second tube, and still fewer on that of the 
third, so that the number of colonies which develop in the 
second tube will be less numerous than in the first tube, 
and those in the third tube still smaller in number. There- 



108 PATHOLOGICAL TECHNIQUE. 

fore, in either the second or the third tube, or in both, the 
bacteria sown may be sufficiently few for discrete colonies to 
develop from them, and among these there may be some 
composed of the bacterium which it is desired to isolate. 
From one of such discrete colonies pure cultures may then 
be prepared as described above. The second and third 
tubes used in this method are called " dilutions." The 
details of the manner of manipulating the tubes, etc. in this 
method may be understood from the description given on 
page 105 and from Fig. 21. 

The Plate Method of Petri. — Another method for obtaining 
discrete colonies of an organism from a mixed growth of 




Fig. 22. — Petri dish with colonies. 

several species is that known as the plate method of Petri. 
This is a modification of the original complicated method 
of Koch. 

The method consists in making " dilutions " in melted 
agar-agar or gelatin tubes, and then pouring the infected 
medium into shallow glass dishes (Fig. 22) previously steril- 
ized, in which it is allowed to solidify. A few bacteria are 
thus distributed throughout a thin layer of culture-medium 
in the " dilutions," and the colonies which develop from them 
are then more or less separated from one another, so that 
pure cultures may be obtained from them. In carrying out 
this method the procedure is as follows : 



BACTERIOLOGICAL EXAMINATIONS. 109 

Three sterile gelatin or agar-agar tubes are melted by heat 
and placed in a water-bath warmed to between 40 and 42 
C. for several minutes, to bring the culture-medium to this 
temperature. This temperature is important especially in the 
case of agar-agar, for it is just above the solidifying point of 
that medium (3 8° C.) and yet not injurious to the vitality of 
the bacteria. The tubes are then infected successively from 
the bacterial growth or from the pathological material from 
which it is desired to obtain discrete colonies, in the same 
manner as described for the method with blood-serum tubes 
— viz. one tube being inoculated from the growth or tissue, 
a second tube or dilution from the first tube, and a third tube 
or dilution from the second tube, the platinum wire being 
sterilized after each inoculation. For making the " dilu- 
tions " a platinum wire bent into the form of a small loop 
(see page 72) is to be used, and as much of the culture-fluid 
as will adhere to it used for inoculating. The wire should 
be moved back and forth several times in the medium of each 
tube when inoculating it, in order to ensure a good distribu- 
tion of the bacteria throughout the fluid. The contents of 
each tube thus inoculated are then poured into sterilized Petri 
dishes, in which the culture-medium solidifies in a thin layer. 

The Petri dishes (Fig. 22) are of clear glass, circular in 
form, 10 cm. in diameter and about 1 cm. deep. Each is 
provided with a loosely fitting flat cover of glass. These 
dishes with their covers are to be sterilized before using by 
placing them in the steam sterilizer for half an hour or by 
heating them to 150 C. in the hot-air sterilizer. When cool 
they are ready to receive the contents of the inoculated test- 
tubes. In pouring, the cover of the dish is not to be re- 
moved any more than is necessary, and it is to be immedi- 
ately replaced, so that contamination from the air may be 
better avoided. It is very desirable that there be no dust 
about the place where the dishes are " poured," and no cur- 
rents of air. 

If agar-agar is used, the dishes thus prepared are to be 
put in the incubator for eighteen to twenty-four hours as 
soon as the medium is solid, which it becomes in a few min- 



no 



PA THOL O GICAL TECHNIQ UE. 



utes ; but if gelatin be used, the dishes are to be set aside in 
a cool place, free from dust, to solidify, and are then to be 
kept at room-temperature for several days. Colonies first 
begin to appear in the gelatin usually after forty-eight hours. 
The method of Petri is of great utility in the study of bac- 
teria from the botanical standpoint, for it is especially adapted 
for the study of the appearances of colonies under the low 
power of the microscope. It is, however, inferior to the 
method with blood-serum tubes for routine pathological 
work, for the following reasons : First : Certain pathogenic 
bacteria grow only feebly on the culture-media which it is 
necessary to employ in this method, while they grow com- 
paratively vigorously on blood-serum. Second: The method 
is complicated and much more troublesome and time-con- 
suming than the simple method described above. 

Esmarch's Method of Roll-cultures. — A third method for ob- 
taining discrete colonies is that of Esmarch as modified by Stern- 
berg. It consists in melting and inoculating three gelatin or agar- 
agar tubes as described for the plate method of Petri, and then 




Fig. 23. — Esmarch tube on block of ice (redrawn after Abbott). 

distributing and solidifying the infected culture-medium over the 
inner surfaces of the tubes in the form of a thin layer by rolling the 
tubes on a block of ice while the medium in them is still fluid 
(Fig. 23). As in the plate method of Petri, the end in view is 
the distribution of a few bacteria throughout a thin layer, and the 
consequent development from them of discrete colonies. 

The tubes used for this purpose should contain sufficient cul- 



BACTERIOLOGICAL EXAMINATIONS. Ill 

ture-medium to fill them to a depth of about 2 cm., but not much 
more than this, for with a greater quantity the preparation of a 
thin layer is difficult. 

In carrying out this method it is best to first make a depression 
in a block of ice with a test-tube filled with hot water. In this 
depression the culture-tube containing the fluid is placed in a 
nearly horizontal position, and rotated rapidly with the fingers 
until the medium is properly distributed and solid, care being 
exercised not to permit the medium to come in contact with the 
cotton stopper. The even distribution of the medium over the 
inner surface of the tube is best obtained by manipulating the tube 
while the medium is still fluid, in such a way as to moisten its 
inner surface up to about 1 cm. of the cotton stopper before pro- 
ceeding to rotate it on the ice. 

Gelatin is the best culture-medium to use in this method. Agar- 
agar can be used, but has the great disadvantage of readily slip- 
ping down toward the bottom of the tube if the tube is placed 
upright. It is necessary, therefore, to keep the tubes on their 
sides. The method has little or no advantage over the method 
of Petri. 

The Determination of the Motility of Bacteria.— 

This is done by observing the individual organisms, un- 




FlG. 24. — The " hanging drop " seen from above and in profile. 

stained, in a drop of bouillon or similar fluid under the oil- 
immersion lens. For this purpose a so-called " hanging drop" 
is prepared, for which a special form of slide known as a 
"hollow slide" is necessary. The hollow slide is a slide 
having a shallow circular concavity, about 1 cm. in diam- 
eter, ground out in its center (Fig. 24). 

In preparing a hanging' drop the procedure is as follows : 
A small drop of a bouillon culture or of the water of con- 
densation of a blood-serum or agar-agar slant is placed in 
the center of a cover-glass by means of the platinum wire. 



112 PATHOLOGICAL TECHNIQUE. 

The cover-glass is then placed, drop downward, over the 
circular depression in the hollow slide. To hold the cover- 
glass in its place and to prevent evaporation of the fluid in 
which the organisms are suspended, a little vaselin is painted 
around the margin of the depression before placing the 
cover-glass in position. The hanging drop thus prepared is 
then examined by focusing upon it with the oil-immersion 
lens, a small aperture of the iris diaphragm of the conden- 
ser being used to render the bacteria visible by refraction. 
To facilitate focusing, the edge of the drop should be 
brought into the center of the field of the low-power ob- 
jective, and then the oil-immersion put in place and focused 
upon it, the edge of the drop being more readily seen as a 
sharp line, owing to refraction, than the organisms. Great 
care is necessary to avoid breaking the cover-glass in the 
effort to bring the bacteria into view. Hanging drops may 
also be prepared from suspensions of bacteria grown on solid 
media, by mixing a portion of the growth with a small quan- 
tity of bouillon. 

In the study of spore- formation the hanging drop is of great 
utility. Here the slide and cover-glass must be carefully steril- 
ized before using, the cavity between the cover-glass and the slide 
well sealed with vaselin, and other precautions taken to prevent 
contamination of the drop with other bacteria. The preparations 
may be placed in the incubator or on a "warm stage " and the 
process of spore-formation followed. 

3. THE INOCULATION OF ANIMALS. 

The animals ordinarily used in the laboratory are guinea- 
pigs, rabbits, and mice. The instruments, etc. used in the 
inoculation of animals should be sterilized beforehand, but 
strict surgical asepsis is not necessary as a rule. 

Guinea-pigs are in most instances inoculated either sub- 
cutaneously or into the peritoneum. 

Subcutaneous inoculation is effected either by injection with 
a hypodermic syringe (see page 71) or by the introduction 
of the material to be inoculated through a small incision in 
the skin. The best point for subcutaneous inoculation is 
the tissue of the anterior abdominal wall. 



BA CTERIOL GICA L EXA MINA TIONS. I I 3 

In inoculating, the animal is to be held abdomen upper- 
most by an assistant, who grasps the neck and fore quarters 
with one hand and the hind quarters with the other. If the 
skin is to be incised, the hair about the point of inoculation 
is to be cut short with a pair of scissors and the skin cleansed 
with soap and water. An incision is then to be made about 
8 or 10 mm. long through the skin, including the subcuta- 
neous tissue, and the superficial tissues separated from the 
muscle for a distance of 10 or 15 mm. toward one side of 
the wound by inserting the points of scissors or other in- 
strument, so as to form a " pocket " beneath the skin. In 
this " pocket " the material for inoculation is introduced, 
either on the platinum wire (see page 72) or by means of 
small forceps. 

If pieces of tissue are used, it may be well in some cases 
to close the wound by one or two sutures in order to pre- 
vent the extrusion of the material after the release of the 
animal. 

Intraperitoneal inoculation may be performed essentially as 
above indicated. If the inoculation be by incision, the open- 
ing into the peritoneal cavity should be as small as possible, 
and the wound should be firmly closed with silk sutures in 
order to prevent extrusion of the intestines. 

In inoculating with the hypodermic syringe the needle 
should not be pushed in too far or the intestines may be 
wounded. The needle is best introduced a little to one side 
of, or slightly below, the umbilicus. 

Rabbits. — These animals may be inoculated both sub- 
cutaneously and intraperitoneally, essentially as described for 
guinea-pigs. 

In lifting or in carrying rabbits from one place to another 
the animals are to be grasped by the ears. During the ope- 
ration of inoculating, the assistant grasps the ears with one 
hand and the hind legs with the other, while the body of the 
animal rests upon the table, abdomen uppermost. Rabbits 
held for a few seconds in this position usually become per- 
fectly quiet, and often do not show any evidence of pain 
during the operation. 



U4 



PA THOL O GICA L TE CHNIQ UE. 



Intravenous inoculation is usually done on rabbits, because 
of the ease with which the needle of a hypodermic syringe 
may be introduced into the long and prominent marginal 
vein of the ear. In inoculating in this manner the tip of the 
ear is held by the thumb and fingers of the left hand, while 
the right manipulates the syringe, the needle of which is 
pushed through the skin of the external surface of the ear 
into the vein which runs along the outer margin of the ear 
(Fig. 25). 




Fig. 25. — Method of making an intravenous injection into a rabbit. Observe 
that the needle enters the posterior vein from the hairy surface (McFarland). 

By the exercise of care and gentleness the animal may be 
thus inoculated without being held by an assistant, especially 
if the fur between the ears be stroked for a short time just 
before the introduction of the needle. In some cases it may 
be necessary to anesthetize the animal on account of violent 
struggling. (See below.) 

Injection of bacteria into the mesenteric veins by means of the 
hypodermic syringe, after laparotomy, may be performed both 
on rabbits and on guinea-pigs. This is to be done under anes- 
thesia. Ether is very satisfactory for this purpose. Guinea-pigs 
bear it well, but it is to be used with caution on rabbits. With the 
latter animals death is liable to occur if the ether is " pushed ' ' after 



BACTERIOLOGICAL EXAMINATIONS. _ 1 1 5 

complete anesthesia is established. Rabbits once thoroughly anes- 
thetized seem to remain so for a considerable time without addi- 
tional ether being necessary. The incision for this form of inocu- 
lation should be in the lower half of the abdominal wall in the 
median line, for in this region the coils of the small intestine are 
most numerous. The length of the incision should be about 2 
cm. Several loops of intestine are brought out through the 
wound, and a mesenteric vein of the proper size to admit the 
needle of the syringe (see page 71) sought for. When found the 
needle is to be introduced and held firmly in position while an 
assistant carefully presses inward the piston of the syringe. After 
the injection of the material the needle is withdrawn, the punc- 
tured vein picked up with the artery- forceps, and the vessel tied 
on both sides of the puncture with silk thread. The loops of the 
intestine are then replaced and the wound closed in two layers, 
one consisting of the muscles and peritoneum, the other of the 
skin. The so-called "button-hole stitch" with silk thread is 
very well fitted for the closing of the wound. 

Little or no aseptic precautions are necessary to obtain primary 
union in the wound. Before the operation, however, the hair of 
the region should be cut off close and the skin cleansed with soap 
and water. 

This form of inoculation may be useful in studying the local 
effects of bacteria upon liver-tissue, for large numbers of them 
will be lodged in the capillaries of the liver, and microscopical 
sections of any part of the organ will contain them, so that any 
local lesion produced by them may be subjected to observation 
after variable intervals of time. 

Mice are usually inoculated subcutaneously at the root 
of the tail. The animal, manipulated by means of chemists' 
crucible tongs or a similar instrument grasping his tail, is to 
be persuaded to crawl into a cylinder of wire gauze, about 
8 to 10 cm. long and about 3 cm. in diameter, which is fixed 
on a small board. The cylinder is open at both ends, and 
when the mouse has crawled into it — a thing which he will 
readily do — the end near his tail is bent inward so as to pre- 
vent him from backing out of it, while an ordinary small 
screw-clamp is adjusted firmly to his tail to prevent his es- 
caping through the other end. The animal is thus secured 
and ready for the operation of inoculation. A more com- 
plete form of this apparatus, with a fixed clamp for the ani- 
mal's tail, is shown in Fig. 26. 

In making the inoculation the mouse is pulled backward 
by the tail until his rump is exposed in the end of the cylin- 



u6 



PA THOL O GICAL TECHNIQ UE. 



der, and then with small scissors the hair is cut away over a 
space, approximately I cm. square, about the root of the 
tail. In the center of this a small opening is made through 
the skin 3 or 4 mm. long with small scissors, and through 
the opening the points of the scissors are passed anteriorly 
beneath the skin for a distance of about 1 cm., so as to make 
a " pocket " or cavity by separating the skin from the mus- 
cles. Into the cavity thus formed the material for inocula- 
tion is then to be introduced by means of the platinum wire. 
As a rule, white mice are to be preferred to the wild brown 




FIG. 26. — Mouse-holder, with mouse in position for inoculation. 

variety, on account of the greater ease with which they may 
be handled. 

Mice may also be inoculated in the peritoneal cavity by intro- 
ducing a very few drops of a suspension or a bouillon culture 
of an organism with a hypodermic syringe. 

The quantity of bacteria used for purposes of inoculation 
varies with the organism and with the end in view. In gen- 
eral, it may be said that in inoculating with the growth from 
a solid medium with the platinum wire one or two loopsful 
are used. If bouillon cultures are employed, the quantity 
injected varies from y 1 ^ c.c. to 1 c.c. in most cases. 

In cases where a " suspension " of the growth on a solid 
medium is injected the same quantities are used as in the 
case of bouillon cultures, the density of the suspension de- 
pending upon the operator. A " suspension " may be con- 



BACTERIOLOGICAL EXAMINATIONS. \\J 

veniently prepared by pouring 5 or 8 c.c. of sterile bouillon, 
sterilized water, or 0.6 per cent, sodium chlorid solution (ster- 
ilized) into the tube containing the growth upon solid medium, 
then breaking up the colonies of the growth with the plat- 
inum wire, and shaking the tube. 

The Care of Animals. — Inoculated guinea-pigs should 
be kept in boxes or cages so arranged as to permit of clean- 
ing and disinfection. Cages made of a combination of gal- 
vanized-iron wire netting and galvanized sheet iron are 
to be preferred. The bottom of the cage should contain 
sawdust, and the top may be made to open on hinges. Good 
dimensions for such cages are 16 inches long, 10 inches 
wide, and 10 inches high. They may be satisfactorily dis- 
infected, in most instances at least, by washing with boiling 
water. 

Inoculated mice are well kept in large glass jars with per- 
forated covers. A small amount of raw cotton should be 
provided for bedding. 

The " stock" guinea-pigs and rabbits may be kept together 
in a pen which should have light and ventilation. Guinea- 
pigs breed readily and their young thrive, but this is not 
usually the case with rabbits. Mice may be kept for use in 
a woven-wire cage set in a sheet-iron pan, which will permit 
of the easy removal of excreta. Some raw cotton should be 
furnished for bedding. The young of white mice are diffi- 
cult to raise to maturity. 

Food. — Rabbits and guinea-pigs eat the same things. In 
summer-time, grass, green corn-husks, and green vegetables 
generally are good food for them. In winter, carrots and oats 
form a satisfactory diet. Fresh water should also be supplied. 

Mice may be fed on stale bread soaked in water, oats, bird- 
seed, and occasionally some cheese. Fresh water should be 
furnished, and, if possible, a little milk sometimes. 

4. CULTIVATION WITHOUT OXYGEN (ANAEROBIC CUL= 

TURES). 

Method of Liborius (Fig. 27). — This consists in culti- 
vating the bacteria in the depths of solid media in test-tubes 



Il8 PATHOLOGICAL TECHNIQUE. 

filled to a considerable height, so that oxygen cannot pene- 
trate to them through the thick layer of medium. 

A test-tube is filled about three-quarters full of sterile glu- 
cose gelatin or glucose agar-agar, and its contents boiled for 
a few minutes to expel the excess of oxygen from the me- 
dium. The tube is then immersed in cold water to cool its 
contents rapidly, and then, before the medium becomes solid, 
the tube is placed in a water-bath at 38 to 40 C. for a 
few minutes. When the medium may be assumed to have 




Fig. 27. — Liborius's method of 
making anaerobic cultures. 



Fig. 28. — Buchner's method of 
making anaerobic cultures. 



reached this temperature, it is inoculated with the material 
from which a growth is sought to be obtained, and then 
rapidly solidified in cold water. When solid the end of the 
tube is sealed up. The colonies of anaerobic bacteria de- 
velop only in the deeper layers of the culture-medium. In 
inoculating the tube care should be taken to secure a good 
distribution of the bacteria through the medium. 

The glucose in the medium, being a reducing agent, favors 
the growth of the anaerobic bacteria. Formic acid may be 
used in place of the glucose for the same purpose, in the 
proportion of 0.3 to 0.5 per cent. 



BACTERIOLOGICAL EXAMLNATLONS. 1 1 9 

Method of Buchner (Fig. 28). — This method consists in 
cultivating the bacteria in ordinary " slant " cultures, which 
are kept in an atmosphere from which the oxygen has been 
absorbed by pyrogallic acid. The inoculated " slant " tube, 
provided with a loosely fitting cotton stopper, is placed in a 
larger tube or cylinder which is hermetically closed, and in 
the bottom of which is deposited a quantity of a mixture of 
pyrogallic acid and a solution of potassium hydroxid (6 
grams to 1000 c.c). In preparing this apparatus the pyro- 
gallic acid (in powder) is placed in the bottom of the tube 
first with the culture-tube in position. Then the solution of 
potassium hydroxid is run in, the outer tube or cylinder 
quickly closed, and the stopper sealed with paraffin or some 
other material. 

It is necessary to seal up the apparatus quickly in order 
to obtain the full benefit of the oxygen-absorbing power 
of the pyrogallic acid. The quantity of pyrogallic acid em- 
ployed should be about 1 gram for each 100 c.c. of air-space 
to be exhausted of oxygen, and for every gram of pyro- 
gallic acid 10 c.c. of the solution of potassium hydroxid 
should be used. The culture-tube is to be elevated above 
the surface of the reducing mixture by means of a bent wire. 
Culture-media containing glucose should be used on account 
of the reducing properties of the glucose. 

The substitution of formic acid for glucose in the propor- 
tions of 0.3 to 0.5 per cent, is also recommended, for the same 
reason. 

Esmarch's Method. — This consists in preparing an Es- 
march roll-culture (see page no), of the organism, and, while 
the layer of glucose gelatin is still cold from the ice, filling 
the tube with liquified gelatin and solidifying this rapidly in 
cold water. The end of the tube is then to be sealed air- 
tight. The colonies develop in the layer of gelatin close to 
the side of tube, and thus can be readily studied with low 
magnifying power. 

Bouillon Cultures under Hydrogen. — These are prepared 
by displacing the air in an ordinary culture-tube or other 
vessel containing glucose bouillon by hydrogen, and her- 



120 



PA THO L O GICA L TE CHNIQ UE. 



metically sealing the tube. The bouillon-tube is closed by 
a rubber stopper through which two small glass tubes pass, 
one running to the bottom of the tube, the other extending 
just inside the rubber stopper. 

The tubes outside the stopper are bent at right angles, 
and then, beyond the bends, are constricted by drawing out 
while hot, so as to be readily sealed with the Bunsen flame. 
In the outer ends of the tubes loose plugs of cotton are 
placed, and the apparatus thus prepared is sterilized by 
steam for half an hour. After sterilization and cooling the 
bouillon is infected with the organism, the stopper and its 
glass tubes being removed and replaced with care to avoid 
contamination. The stopper is then sealed in position with 
paraffin or sealing-wax, after which hydrogen from a hydro- 
gen generator is passed through the longer tube leading into 
the bouillon, and thus displaces the air through the shorter 
tube. After the hydrogen has flowed for 
five minutes the glass tubes are quickly 
sealed with the Bunsen flame at the con- 
strictions, and the culture thus prepared 
placed in the incubator. In passing the 
hydrogen through the apparatus the cotton 
plugs must of course be kept in position. 

The generation of hydrogen is best effected 
by means of the well-known apparatus of 
Kipp. It is important that no oxygen be 
present in the gas, or an explosion may occur 
during the sealing of the tubes in the Bunsen 
flame. 

Pure granulated zinc and pure sulphuric 

acid of 25 to 30 per cent, strength should 

be used. Before running the gas into the 

test-tube or other apparatus the reservoir of 

the generator should be allowed to fill with 

gas, and this then allowed to escape into the 

air by opening the outlet, care being taken 

that no flame be near by. This should be 

repeated, and then a sample of the hydrogen 

collected in an inverted test-tube by displacement of water in the 

well-known way. The same should then be ignited, and if no 

explosion occurs the hydrogen is fit to use. 




Fig. 29. — Franker s 
method of making an- 
aerobic cultures. 



BACTERIOLOGICAL EXAMINATIONS. 121 

Cultures under hydrogen on solid media may also be made 
in a manner similar to that described for bouillon cultures. 

An ingenious application of the method above described to 
Esmarch roll-cultures under hydrogen is the so-called Frankel's 
method (Fig. 29). This consists in preparing dilutions in melted 
gelatin tubes, passing hydrogen through the melted gelatin in the 
tubes as in the case of bouillon, so as to displace all of the air, 
sealing the tubes, and then making Esmarch rolls on ice (see page 
no). While filling with the hydrogen the tubes are to be kept in 
a water-bath at about 35 ° C, in order that the gelatin may remain 
fluid. All of the precautions mentioned in the case of bouillon 
are to be observed in order to prevent contamination. 

Plate-cultures by Petri' 's method, or ordinary tube-cultures, may 
also be grown by placing the plates or tubes in a vessel so con- 
structed that hydrogen may be passed into it until all the air is 
displaced, and the vessel is then hermetically closed. The appa- 
ratus of Novy, now on the market, is well adapted for this purpose. 

Before passing in the hydrogen a plug of cotton should be 
placed in each of the tubes of the apparatus, to prevent the access 
of bacteria to the interior. The entire apparatus should also be 
sterilized by steam before the plates are placed in position and be- 
fore the hydrogen is run in. 



V. BACTERIOLOGICAL DIAGNOSIS. 

The number of species of bacteria of pathogenic signif- 
icance which are commonly encountered in pathological pro- 
cesses in man is a small one. These comprise the staphylo- 
coccus pyogenes aureus, the streptococcus pyogenes, the 
pneumococcus, the bacillus coli communis, the typhoid ba- 
cillus, the bacillus diphtheriae, and the bacillus tuberculosis. 
It is with infections with these few species that the patholo- 
gist is most frequently concerned, and the determination of 
the presence of these alone comprises by far the greater part 
of the bacteriological work which he is called upon to do. 

In the following descriptions of the important pathogenic 
bacteria which are concerned in human pathology the main 
object will be to give those characteristics which will serve 
for their identification, rather than an exhaustive consideration 
of their various properties and modes of growth. 

Staphylococcus Pyogenes Aureus. 1 — The colonies 

1 J. Rosenbach : Mikroorganismen bei den Wundinfectionskrankheiten des 
Menschen, Wiesbaden, 1884. 



122 



PA THOL O GICA L TE CHNIQ UE. 




Fig. 30. — Staphylococcus pyogenes aureus, from an agar-agar culture (Giinther). 

on blood-serum are golden yellow in color. They are 
rounded, shining, slightly elevated, and may attain a diam- 




FlG. 31. — Staphylococcus pyogenes aureus: stab-culture three days old in gela- 
tin (Frankel and Pfeiffer). 

eter of 2 mm. or more after remaining for thirty-six hours in 
the incubator. The color of the colonies varies from a pale 



BACTERIOLOGICAL EXAMINATIONS. 1 23 

yellow to a deep orange. Young colonies may be creamy 
white, becoming yellow later. 

Morphology. — Rather small cocci, frequently arranged in 
masses or clumps. 

Stained by Gram's method. 

Gelatin Stab-culture. — Growth along the line of stab, fol- 
lowed by liquefaction in funnel form, with yellow sediment 
and clouding of the liquefied medium (Fig. 31). 

Potato. — Yellow confluent colonies. 

Agar-agar Slant. — Rather broad shining streak with 
sharply defined margins, at first white in color, but later 
becoming yellow. 

Bouillon. — Densely clouded. A yellowish sediment is 
formed, and sometimes a thin pellicle is seen on the surface. 

Litmus-milk. — Turned pink and coagulated. 

Pathogenesis. — When inoculated into the circulation of a 
rabbit death follows in from eighteen hours to three days in 
the case of virulent cultures. Not all specimens of this 
organism are virulent. The lesions produced in the rabbit 
by inoculation in the ear-vein in typical cases are abscesses 
with infarctions in the kidneys, and miliary abscesses in the 
myocardium, diaphragm, and voluntary muscles. In the 
kidneys lines of necrosis with purulent infiltration, mainly in 
the pyramids, are frequently observed. This organ is the 
one most constantly affected. The number and extent of 
the lesions vary in different animals and with different cul- 
tures. They are best developed in animals which survive 
about three days. In animals which succumb after eighteen 
hours no macroscopic change may be apparent. On micro- 
scopical examination of the kidneys, however, small areas of 
necrosis will usually be found, mainly in the pyramids, sur- 
rounding masses of cocci. In the kidneys of animals which 
survive longer all the grades of invasion of these necrotic 
areas by leucocytes, up to regular abscess-formation, may be 
traced. By cultures the organism will be found in large 
numbers in the kidneys and urine of the rapidly fatal cases, 
and in smaller numbers in the other organs and blood of the 
heart. 



124 PATHOLOGICAL TECHNIQUE. 

Occurrence. — The staphylococcus pyogenes aureus is found 
most commonly in pus-formations of a circumscribed cha- 
racter and also in a large number of pathological conditions, 
of which only the more important will be mentioned here. 

These are as follows : Osteomyelitis, peritonitis, pleuritis, 
endocarditis, meningitis, broncho-pneumonia, and puerperal 
septicemia. It may also be found in the blood of the various 
internal organs at autopsies in cases in which a suppurative 
or other acute inflammatory process is present anywhere, 
with or without metastatic abscess-formation. The organism 
also occurs frequently in the dust of places inhabited by 
man, as well as on the surface of the skin and of the mu- 
cous membranes of the nose and mouth. 

The following staphylococci may also be present in acute 
inflammatory processes, but they occur less frequently than 
does the staphylococcus pyogenes aureus. 

Staphylococcus Pyogenes Albus and Staphylococcus 
Pyogenes Citreus. — These organisms differ from the staphylo- 
coccus pyogenes aureus mainly in the color of their colonies. 
As a rule, they are much less pathogenic for rabbits than that 
organism. 

Staphylococcus Bpidermidis Albus (Welch). — "Is prob- 
ably only a variety of the staphylococcus pyogenes albus. Usu- 
ally grows somewhat more slowly ; liquefies gelatin and coagulates 
milk less rapidly. Is of little virulence under ordinary conditions. 
Is a regular inhabitant of the epidermis, lying deeper than can be 
reached by disinfection of the surface of the skin " (Welch). 

Staphylococcus Cereus Albus. — Very similar to the staph- 
ylococcus pyogenes albus, but does not liquefy gelatin. May 
occur in abscesses. 

Staphylococcus Cereus Flavus. — This organism is similar 
to the preceding, except that it forms a lemon-yellow pigment. 

Streptococcus Pyogenes. 1 — This organism may be re- 
garded as identical with the streptococcus erysipelatos of Feh- 
leisen. 2 

Blood-serum. — Minute grayish-white colonies, often look- 
ing like small grains of sand scattered over the surface of 
the medium. Sometimes the colonies are shining, trans- 
lucent, colorless, resembling minute dewdrops. 

1 Rosenbach : loc. cit., p. 121. 

2 Fehleisen : Die Aetiologie des Erysipels, Berlin, 1883. 



BACTERIOLOGICAL EXAMINATIONS. 1 25 

Morphology. — Rather small cocci arranged in chains, each 
coccus being divided into two hemispheres by a line of 
division running at right angles to the axis of the chain 







i*. •-*£ 




FIG. 32. — Streptococcus pyogenes ; cover-glass preparation of the pus of an 
abscess ; X 1000 (Frankel and Pfeiffer). 

(Figs. 32, 33). The chains may be made up of many cocci 
and be quite long. 

Cover-glass preparations from the colonies often fail to 
show the characteristic chain arrangement, owing to the 
chains being broken up by the manipulation. The chain- 



f^c 



lM> 



ScflW. 



FlG - 33- — Streptococcus pyogenes (from a bouillon-culture). 

formation is best demonstrated in cover-glass preparations 
from the " water of condensation " at the bottom of the 
blood-serum tube. This is essentially a bouillon culture 



126 PATHOLOGICAL TECHNIQUE. 

and it is in such fluid media that the chain-formation is best 
developed. In preparing the cover-glass from this as little 
manipulation of the fluid as possible should be used, in 
order to avoid destroying the chain arrangement. 

Practically, the only organism with which the strepto- 
coccus may be confounded is the pneumococcus, which also 
grows in minute colonies and sometimes in chains. The 
streptococcus may be distinguished from the pneumococcus, 
however, by the morphology of the individual organisms, 
the streptococci appearing as pairs of hemispheres, and the 
pneumococci as pairs of oval, conical, or lancet-shaped or- 
ganisms, the broader ends of which are in apposition. 

Stains by Gram's method. 

Bouillon. — The character of the growth in bouillon is sub- 
ject to considerable variation, and certain doubtful varieties 
of the streptococcus are distinguished mainly by the bouil- 
lon culture. 

" We thus distinguish short-chained streptococci (' strepto- 
coccus brevis '), long-chained streptococci (' streptococcus 
longus '), streptococci which render bouillon cloudy and 
those which do not, streptococci which form flocculent or 
scaly or sandy or viscous sediments. 

" The name • streptococcus conglomeratus ' is given to a 
streptococcus which grows, without clouding the bouillon, in 
the form of dense, separate particles, scales, or thin mem- 
branes at the bottom or sides of the tube, and on shaking 
the sediment it breaks up into little specks, without produ- 
cing uniform diffuse cloudiness. 

" On microscopical examination the chains in the latter 
case are long and interwoven in conglomerate masses. 
Streptococcus chains may be straight or wavy or twisted. 
These various distinctions are only of relative value. One 
form may change into another. Virulent streptococci may 
be found among all the groups mentioned ; the streptococci 
of erysipelas and most of the streptococci from abscesses 
and septicemia grow in long chains in bouillon " (Welch). 

Agar-agar Slant. — Minute grayish translucent colonies 
(Fig. 34)- 



BA CTERIOL O GICAL EXAMINA TIGNS. 



127 



Agar-agar Stab. — Small spherical grayish colonies along 
the needle-track. 

Gelatin. — Growth similar to that on agar-agar. 

Litmus-milk. — Some varieties turn the medium pink and 
cause coagulation. 

Pathogenesis. — The results of the inoculation of animals 
are not constant, great variation in the virulence of dif- 
ferent cultures being observed. Some- 
times mice inoculated at the root of the 
tail or in the peritoneal cavity will die 
in about twenty-four hours with en- 
largement of the spleen and large 
numbers of the organism in the inter- 
nal organs. 

Occurrence. — The streptococcus oc- 
curs frequently in the spreading phleg- 
monous inflammations as well as in 
suppurative processes generally, and 
is the most common cause of septice- 
mia. It is almost always present in 
inflammatory conditions of the mucous 
membrane of the pharynx, and is often 
encountered in broncho-pneumonia. 
In erysipelas it is almost invariably 
the infecting organism, and it is the 
most frequent cause of puerperal sep- 
ticemia. In the majority of fatal cases 
of diphtheria and in some cases of 
typhoid fever, scarlet fever, tubercu- 
losis, and other acute inflammatory 
diseases it will be found in the blood 

of the various internal organs after death. It also occurs in 
a certain proportion of cases of peritonitis, pleuritis, men- 
ingitis, endocarditis, and otitis media. Gaining entrance to 
the tissues through an insignificant wound or abrasion of 
the skin, it may produce a rapidly fatal septicemia in a sus- 
ceptible individual, in whose internal organs at autopsy large 
numbers of the organism will be found. This general inva- 




Fig. 34. — Streptococcus 
pyogenes : culture upon 
agar-agar two days old 
(Frankel and Pfeiffer). 



128 PATHOLOGICAL TECHNIQUE. 

sion of the circulation may also be observed in cases of 
chronic or wasting disease, the infection occurring during 
the last days or hours of life (terminal infection). 

Of other conditions in which it may occur, hepatic abscess, 
appendicitis, osteomyelitis, and synovitis may be mentioned. 
Although the streptococcus is distinctly one of the pus-pro- 
ducing bacteria, yet the inflammations of the soft parts of 
the extremities which are produced by it are generally cha- 
racterized more by necrosis and serous or hemorrhagic exu- 
dation and infiltration than by the breaking down of tissue 
and frank pus-production. In this the organism is in marked 
contrast to the staphylococcus pyogenes aureus, which 
practically always produces dissolution of tissue and pus. 
Moreover, the streptococcus inflammations are more com- 
monly accompanied by lymphangitis than are those due to 
the staphylococcus pyogenes aureus. 

In a few instances we have met with a streptococcus whose 
colonies assume a well-marked yellow color on blood-serum, but 
which in other respects are like the long-chained forms above de- 
scribed. 

Pneumococcus. 1 — Synonyms: Diplococcus pneumoniae; 
Micrococcus lanceolatus ; Micrococcus of sputum-septi- 
cemia : Micrococcus pneumoniae crouposae. 

Blood-serum. — Minute colorless, transparent colonies, re- 
sembling very small drops of dew. 

Morphology. — Pairs of rather small oval, conical, or lancet- 
shaped organisms, the broader ends being in apposition. 
The organism varies somewhat in size, and one of the "pair" 
may be smaller than the other. In some cases atypical or in- 
volution forms are seen, especially if the culture be more 
than twenty-four hours old. No capsules are ordinarily ob- 
served in cultures with ordinary methods of staining. In 
the "water of condensation " of the blood-serum tube chains 
may be formed resembling those of the streptococcus, but 
differing from the chains of that organism by the oval or 
lancet form of the elements of which they are composed. 

1 A. Frankel : Zeitschrift fur klinische Medicine, Bd. x. u. xi. ; Weichsel- 
baum : Wiener tried. Jahrbiicher, 1886. 



BACTERIOLOGICAL EXAMINATIONS. 1 29 

Stained by Gram's method. Not motile. 

Glycerin Agar-agar. — Feeble growth of very minute gray- 
ish colonies. 

Bouillon. — Clouded faintly. 

Litmus-milk. — Sometimes turned pink and coagulated. 
Growth on other culture-media is very feeble. The organ- 




FlG. 35. — Diplococcus pneumoniae ; cover-glass preparation from the heart's 
blood of a rabbit; X 1000 (Frankel and Pfeiffer). 

ism dies out rapidly in cultures. To keep it viable it should 
be transplanted every forty-eight hours. 

Pathogenesis. — The pneumococcus is very pathogenic for 
mice and rabbits, less so for guinea-pigs. 

Subcutaneous inoculation with virulent cultures causes the 
death of mice in from twenty-four to thirty-six hours, and 
of rabbits in from thirty-six to forty-eight hours, with septi- 
cemia. 

This infection is the " sputum-septicemia " of Sternberg. 
At the autopsy there will be found in the blood everywhere 
the characteristic encapsulated lancet-shaped organisms, usu- 
9 



130 PATHOLOGICAL TECHNIQUE. 

ally in pairs (Fig. 35). Great variation in the virulence of 
the organism is observed. In some cases no effect will be 
produced by the inoculation ; in others a more or less exten- 
sive fibrino-purulent exudation will be produced about the 
point of inoculation, and the animal will survive for a con- 
siderable length of time or recover. Inoculation into the 
ear-vein or peritoneal cavity of a rabbit will sometimes cause 
a rapidly fatal septicemia, when subcutaneous inoculation with 
the same culture will only cause a local reaction. The viru- 
lence of the pneumococcus is quickly lessened by cultivation. 

Occurrence. — The pneumococcus may be demonstrated in 
the pulmonary exudate of practically all cases of genuine 
lobar or croupous pneumonia. At autopsies on cases of this 
disease it may be found in large numbers in the consolidated 
lung, and sometimes in smaller numbers in the blood of 
other internal organs. Cultures from the lung may some- 
times show the presence of other bacteria in addition to the 
pneumococcus, but these are to be regarded as either second- 
ary infections or contaminations from the smaller bronchi. 

The pneumococci in the pneumonic exudate die in large 
numbers after a time, and in cases near resolution numerous 
capsules may be found in cover-glass preparations from the 
lung in which it is impossible to demonstrate the organism 
by staining methods. 

The pneumococcus is also frequently found in broncho- 
pneumonia, acute peri- and endo-carditis, acute pleuritis and 
empyema, acute purulent meningitis, and in otitis media. It 
has been observed in cases of peritonitis, of synovitis, of os- 
teomyelitis, and of abscess-formation in various situations. 

At autopsies on individuals dead of these conditions it 
may be frequently found, by means of cultures and animal 
inoculations, generally distributed throughout the internal 
organs in variable numbers. It is also often present in the 
mouth and in the saliva of healthy individuals. 

GonococctlS. 1 — Morphology. — Cocci of medium size, com- 

1 Neisser : Centralbl. f. d. med. Wissenschaften, No. 28, 1879; Bumm : Der 
Mikroorganismus der gonorrhoischen Schleimhauterkrankungen — " Gonococcus 
Neisser" Wiesbaden, 1887 ; Wertheim : Archiv f. Gynacologie, Bd. 42, 1892. 



BACTERIOLOGICAL EXAMINATIONS. 131 

posed usually of two hemispheres separated by a narrow 
unstained interval. Sometimes two of these pairs of hemi- 
spheres are joined together in the manner of " tetrads," or 
groups of four, showing evidence that division occurs in two 
directions at right angles to each other. Decolorized by 
Gram's method. 

The gonococcus will not grow upon any of the culture- 
media ordinarily employed, but requires special media for 
its cultivation. 

The colonies on suitable culture-media appear after eighteen 
to twenty-four hours as minute, grayish, translucent points. 
Later they may attain a diameter of 2 mm. Under low 
magnifying power a well-developed colony is seen to consist 
of a generally circular expansion, with thin, translucent, 
sharply-defined margins, becoming brownish, granular, and 
denser toward the center, which is made up of coarse brown- 
ish clumps closely packed together. 

Special Culture-media. — The essential constituent of cul- 
ture-media upon which the gonococcus will grow seems to 
be the blood-serum or similar albuminous fluid from the 
animal body. 

Serum Agar-agar. — This medium consists of sterile human 
blood-serum mixed with fluid agar-agar at a temperature of 
40 C. in the proportion of 1 part of blood-serum to 2 or 3 
parts of agar-agar. The blood-serum is to be obtained 
under the strictest precautions to avoid contamination with 
bacteria, thoroughly sterilized vessels, etc. being used. The 
blood may be conveniently drawn from the median vein of 
the arm with a sterilized antitoxin syringe. Placental blood 
obtained from the umbilical cord by pressure on the pla- 
centa may be also employed. 

Ordinary tubes of plain agar-agar which have been pre- 
viously sterilized in the usual manner are melted and brought 
to a temperature of 40 C. in a water bath. To the fluid 
agar-agar in each tube the sterile blood-serum is then added 
in the proportion of one-third to one-half the volume of the 
agar-agar, care being taken to avoid contamination. For 
the transfer of the serum to the agar-agar tubes a sterilized 



132 PATHOLOGICAL TECHNIQUE. 

pipette may be used. The tubes may then be infected and 
their contents poured into sterilized Petri dishes, as in the 
plate method previously described (see page 108), or the tubes 
may be placed on their sides in a slightly inclined position 
and the agar-agar allowed to solidify, thus forming " slants " 
which may be kept on hand ready for use. In order to test 
for the presence of contaminating bacteria in these slants, it 
is well to place them in the incubator for twenty-four hours 
after they have become solid, so that any bacteria which may 
be present in them will form colonies and manifest them- 
selves. If only two or three tubes of this media are required, 
they may be prepared by drawing a suitable quantity of blood 
from the median vein of the arm with a sterilized hypodermic 
syringe, mixing this blood directly with tubes of melted agar- 
agar, as above indicated, and allowing the mixture to solidify 
to form " slants." A thorough cleaning of the skin about 
the vein is of course necessary. Some pathological fluids 
which are rich in albumin, such as the serous exudate of 
pleuritis, may be used in the place of blood-serum as above 
described. In using these, however, it is important to be sure 
that they contain albumin in considerable quantities, for they 
vary greatly in this respect, and those which contain but little 
albumin will probably be of no value for the purpose. 

Urine-Serum- Agar-agar. — This medium is prepared by mix- 
ing, under aseptic precautions, with melted agar-agar at a tem- 
perature of about 40 C, one-third to one-half its volume of 
a sterile mixture of beef blood-serum and human urine. 1 The 
mixture of blood-serum and urine consists of 1 part urine and 2 
parts serum. This mixture is freed from bacteria by filtration 
through a large unglazed porcelain filtering apparatus, and it is 
then added to the ordinary sterilized agar-agar (plain) tubes, which 
have been melted down and are kept fluid in a water-bath at about 
40 C. After the admixture of the urine and serum with the agar- 
agar, the contents of the tubes are allowed to solidify in the form 
of "slants," and then tested for contaminations by placing the 
tubes in the incubator for twenty-four hours. The agar-agar, if 
used, should be more concentrated than usual to allow for the 
addition of the urine and serum. This concentration can best 

1 J. H. Wright : " On the Cultivation of the Gonococcus from Cases of Gon- 
orrhea, Ophthalmia Purulenta, and Pyosalpinx " [Amer. Jownal Med. Set., 
Jan., 1895). 



BACTERIOLOGICAL EXAMINATIONS. 1 33 

be obtained by evaporating the agar-agar before running it into 
the tubes to about three-fifths of its proper volume. Thus a liter 
of agar-agar may be evaporated by boiling to 600 or 700 c.c. 
The tubes should be filled with this concentrated agar-agar to a 
depth of about 3 cm. The filtering apparatus should be sterilized 
by steam before using, as also everything which comes in contact 
with the culture material. A half hour in the steam sterilizer 
will suffice for the purpose. 

The gonococcus is not pathogenic for laboratory animals, 
as is the case with certain other pathogenic bacteria. When 
inoculated with bits of agar into the eye or into the perito- 
neal cavity of mice and guinea-pigs it may give rise to sup- 
puration. 

Occurrence. — The presence of the gonococcus may be 
demonstrated in the pus of acute gonorrhea and gonorrheal 



't&^M % 







Fig. 36. — Micrococcus tetragenus: colony twenty-four hours old upon the sur- 
face of an agar-agar plate ; X 100 (Heim). 

ophthalmia. It occurs also in a certain proportion of cases 
of purulent salpingitis. It has been found in peritonitis, en- 
docarditis, pericarditis, myocarditis, pleuritis, and arthritis, as 
well as in periurethral abscess, in abscess of the glands of 
Bartolini, and in other acute inflammatory processes. 

Micrococcus Tetragenus. 1 — The colonies are small, 
white, and elevated (Fig. 36). Growth is slow. 

1 Koch: Mitth. a. d. Kais. Gesundheitsamte, Bd. 2, 1884; Gaffky : Arch. f. 
Hlin. Chirurgie, Bd. 28. . 



134 PATHOLOGICAL TECHNIQUE. 

Morphology. — Micrococci arranged in fours, or " tetrads," 
held together by a gelatinous substance (Fig. 37).- 

Stained by Gram's method. Not motile. 

Gelatin Stab. — Feeble growth in the form of minute 
spherical masses along the line of stab with a small white 
slightly elevated point at the surface of the medium. The 
gelatin is not liquefied. 

Agar-agar Slant. — Moist, glistening, grayish-white trans- 
lucent streak with wavy margins. 

Potato. — Growth is in the form of "a thick, irregular, 







FlG. 37. — Micrococcus tetragenus in pus from a white mouse; X 615 (Heim). 

slimy-looking patch." l The growth on agar-agar and on 
potato may be drawn into thin threads by the platinum wire. 

Pathogenesis. — Subcutaneous inoculation of mice and 
guinea-pigs may lead to a fatal septicemia or only a local 
pus-formation. Intravenous or intraperitoneal inoculation of 
rabbits may also produce septicemia and death. 

At autopsy the micrococci, arranged in tetrads, are found 
in the blood generally, but most numerously in the spleen. 
They can readily be demonstrated by cover-glass prepara- 
tions. 

Occurrence. — " Found not infrequently in phthisical cavities 
and sputum, occasionally in association with pyogenic cocci 
in abscesses connected with carious teeth and about the neck 

1 Abbott : Principles of Bacteriology. 



BA CTERIOL O GICAL EXAMINA TIONS. 



135 



and jaws and middle ear, rarely in abscesses elsewhere. It 
has been considered to be non-pathogenic for man, but it has 
been found in pure culture in closed abscesses in man, and 
Viquerst has proven experimentally that it is capable of caus- 
ing suppuration in human beings " (Welch). 

Diplococcus Intracellularis Meningitidis. 1 — Mor- 
phology. — Diplococci, occurring as paired hemispheres, sepa- 
rated by a well-marked unstained interval and showing con- 



*? 







FIG. 38. — Diplococcus intracellularis meningitidis : from a culture (Jaeger). 



siderable variation in size in cultures (Fig. 38). The larger 
forms are regarded as involution or degenerate forms. 

In cover-glass preparations from the meningeal exudate 
the diplococcus frequently is situated inside leucocytes, and 
sometimes within the nucleus (Fig. 39). The appearances 
are very much like those of gonorrheal pus. It is decolor- 
ized by Gram's method. 

1 Weichselbaum : Fortschritte der Medicine, Bd. 5, 1 887 ; 
schrift fur Hygiene und Infectionskrankheiten, Bd. 19, 1895 
Transactions of the Association of American Physicians, 1897. 



Jaeger : Zeit- 
Councilman : 



I3 6 PATHOLOGICAL TECHNIQUE. 

Blood-serum. — The colonies appear after about twenty-four 
hours, and after forty-eight hours may attain a diameter of 
2 or 3 mm. They are round, colorless, shining, slightly 
convex or flat, moist, and viscid-looking. They may be- 
come confluent. 

Agar-agar. — Round, flat, grayish, translucent, moist, shin- 
ing colonies, attaining a diameter of 2 or 3 mm. after twenty- 





Fig. 39. — Diplococcus intracellularis meningitidis in polynuclear leucocytes of 
meningeal exudate (Jaeger). 

four hours in the incubator. They may become confluent, 
and in a " slant " culture the growth appears as a grayish, 
translucent, moist, shining streak about 3 mm. in width, with 
smooth margins. Under a low magnifying power the colo- 
nies are homogeneous, semi-translucent, and not granular. 

Sugar-agar Stab-culture. — Feeble growth not extending 
all along the line of inoculation. 

Bouillon. — Medium slightly to moderately clouded. At 
the bottom of the tube a whitish sediment, which may rise 
as a viscid string when the tube is shaken. 



BACTERIOLOGICAL EXAMINATIONS. I 37 

Potato. — Very feeble or doubtful growth, giving the surface 
of the potato a moist appearance at the most. 

Litmus-milk. — Growth without visible change in the 
medium. 

Gelatin. — Feeble growth. No liquefaction. 
Vitality. — The organism quickly dies out under cultivation. 
It seems to survive somewhat better on blood-serum than 
on agar-agar, but cultures on the former only seventy-two 
hours old may be found no longer capable of growth after 
transplantation. 

Pathogenesis. — Intraperitoneal inoculation of guinea-pigs 
and rabbits gives very uncertain results. Mice are said to 
succumb to subcutaneous inoculation, with some invasion of 
the blood by the organism. 

Exceptionally, we have found that the intraperitoneal in- 
jection of a bouillon suspension of a twenty-four-hour 
blood-serum culture in the quantity of about 1 c.c. would 
kill guinea-pigs within forty-eight hours. 

At the autopsy there is an accumulation of a cloudy or 
blood-stained fluid in the peritoneal cavity, some little en- 
largement of the spleen, and some injection of the perito- 
neum. Microscopical examination of the exudate shows 
numerous leucocytes crowded with the diplococci. The 
culture-test gives no evidence of general infection of the 
blood. 

Occurrence. — Found in the meningeal exudate of certain 
cases of epidemic cerebro-spinal meningitis. It is situated 
mainly inside the pus-cells, some of which may contain 
many diplococci. In some cases the presence of the organ- 
ism in the exudate may be difficult or impossible to demon- 
strate, and it is probable that it rapidly dies out. It has been 
observed in the lung in the broncho-pneumonia of one case, 
and in the nasal secretions of a number of cases. A general 
invasion of the circulation by the organism does not occur. 

Bacillus Diphtherise. 1 — Blood-serum. — Round, elevated, 
smooth colonies of the color of the medium. They may 

1 Loffler: Mitth. a. d. Kais. Gesundheitsamte, Bd. 2, 1884; Roux and Yer- 
sin : Annates de V Institut Pasteur, T. 2-4, 1888-90. 



I38 PATHOLOGICAL TECHNIQUE. 

attain a diameter of 2 mm. after forty-eight hours in the 
incubator. 

Morphology. — Bacilli varying markedly in size and shape, 
of irregular outline, and showing great variability in the 
staining of different parts of their protoplasm (Fig. 40). 
The presence in a palely tinted rod of deeply stained 
granules and points, frequently situated at the extremities, 
and the occurrence of irregular forms, often club-like in shape 
with a constriction in the middle, are appearances which are 
very characteristic of the bacillus when grown upon blood- 



^X^ 



% 

'a 






p.- J#w 



^*s tip' M ' 



fir 



<& 



FIG. 40. — Bacillus diphtherias, from a culture upon blood-serum ; X iooo 
(Fr'ankel and Pfeiffer). 

serum and stained with Loffler's methylene-blue solution. 
Its morphology and staining peculiarities are so characteristic 
when cultivated upon blood-serum that the microscopical 
examination is in most cases sufficient for its identification. 
When grown upon other culture-media than blood-serum, 
however, its morphology and staining peculiarities are not so 
characteristic, and they may vary markedly in different media. 

Stained by Gram's method. Not motile. 

Bouillon. — Grows usually in the form of fine grains at the 
bottom of the tube and adherent to the sides, the bouillon 



BA CTERIOL O GICAL EXAMINA TIONS. 



139 



remaining clear or becoming slightly clouded. The reac- 
tion of the media rapidly becomes acid, but changes to alka- 
line after a variable length of time. 

Potato. — Growth not visible to the naked eye. The bacil- 
lus grows, however, to a certain extent, and usually assumes 
very atypical and irregular forms (involution forms). 

Agar-ugar and Gelatin. — The growth on these media is 
slower and more feeble than upon 
blood-serum (Fig. 41). It presents 
nothing remarkable. 

Pathogenesis. — Subcutaneous inocu- 
lations of guinea-pigs are fatal in thirty- 
six to seventy-two hours in the case of 
virulent cultures. The lesions pro- 
duced consist usually of edema, hem- 
orrhage, and fibrino-purulent exuda- 
tion about the point of inoculation in 
the subcutaneous tissue, hemorrhagic 
enlargement of the lymphatic glands, 
congestion and edema of the lungs, 
hemorrhages into the suprarenal cap- 
sules, and less frequently necrosis of 
the liver and pleural effusions. His- 
tological examination of the lymph- 
glands shows marked "fragmentation " 
of the nuclei of the cells, giving rise 
to numerous deeply staining globules 
of chromatin scattered throughout 
them. The bacilli are ordinarily 
found only about the point of inocu- 
lation, but cultures from the various 
organs will sometimes show the 
presence of the bacilli in some of them. 

Toxin-production. — The effects produced by infection with the 
bacillus diphtherias are due to the action of a so-called toxalbumin 
or " toxin " which the organism manufactures in its growth. The 
poisonous substance is produced in cultures. Its presence may be 
demonstrated by inoculating an animal with a small quantity of 
the nitrate, obtained by passing a bouillon culture some weeks old 




Fig. 41. — Bacillus diph- 
theriae; agar-agar culture 
(photograph by Dr. Henry 
Koplik). 



140 PATHOLOGICAL TECHNIQUE. 

through an unglazed porcelain filtering apparatus, by which all 
the bacteria are removed from the fluid. 

The "toxin" is contained in solution in the filtrate. If this 
be fairly rich in "toxin," the injection of ^ c.c. subcutane- 
ously into a guinea-pig should lead to the death of the animal in 
three or four days with the various lesions above described. The 
local reaction, however, is not so marked as in the case of inocu- 
lation with the bacilli. With the ordinary bouillon the produc- 
tion of a great amount of "toxin " by the growth of the diph- 
theria bacilli in it is very uncertain. Theobald Smith has recently 
shown that this uncertainty is due to the presence of variable 
amounts of muscle-sugar from the meat used in the preparation 
of the bouillon, and that this substance prevents the accumulation 
of toxin. He has found that that bouillon yields the most toxin 
which has the least muscle- sugar in it. According to Smith, the 
best means of obtaining a fluid rich in toxin is as follows : The 
meat destined for use in the preparation of the bouillon is to be 
allowed to decompose during three or four days, in which pro- 
cess most of the muscle-sugar disappears from it. With this 
partially decomposed meat a bouillon is made as described else- 
where, but of such a reaction that 10 c.c. of a normal solu- 
tion of sodium hydrate * per liter of bouillon is necessary to give 
a faint pink coloration with phenophthalein. This bouillon is 
placed in two 500 c.c. Erlenmeyer flasks, 250 c.c. in each flask. 
In these cultures are made and kept for at least eight days in the 
incubator. After this time a fair amount of toxin may be assumed 
to have developed, and the contents of the flask are then filtered 
through a porcelain cylinder. A filtrate is to be regarded as 
containing a reasonable amount of toxin if y 1 ^- c.c, injected 
subcutaneously, kills a medium-sized guinea-pig in three days. 
The filtrate containing the ' ' toxin ' ' can be preserved by the 
addition of 0.5 per cent, pure carbolic acid. 

Occurrence. — The bacillus diphtheriae occurs in the local 
lesions in all cases of true diphtheria, in rhinitis fibrinosa, 
and in many cases of the milder forms of acute inflammation 
of the air-passages. It may persist in the mucous mem- 
brane of the throat and nose long after convalescence has 
been established. 

In fatal cases of diphtheria the organism is nearly always 
present in the lungs, and it may be often found by culture- 
methods more or less generally distributed in compara- 
tively small numbers throughout the internal organs. In 
the majority of diphtheria autopsies an invasion of the blood- 

1 40 grams of sodium hydrate c. p. (by alcohol) dissolved in 1000 c.c. 
of distilled water. 



BACTERIOLOGICAL EXAMINATIONS. 141 

stream by the streptococcus pyogenes, and sometimes by 
other bacteria, may be demonstrated by cultures. The ba- 
cillus may also be found in company with other bacteria in 
ulcerated or excoriated surfaces on the skin, as well as in 
other suppurative processes, in individuals affected with 
diphtheria, and on the soiled linen of the patient. The in- 
fection of wounds with the bacillus diphtherial has also been 
observed without coincident diphtheria. 

Bacillus of Typhoid Fever. 1 — Synonyms: Bacillus 
typhi abdominalis ; Bacillus typhosus ; Typhoid bacillus (see 
also Clinical Bacteriology). 

Blood-serum. — Round, grayish, viscid-looking colonies, 




Fig. 42. — Bacillus of typhoid fever, from a twenty-four-hour agar-agar culture ; 

X 650 (Heim). 

which may attain a diameter of 2 mm. after forty-eight hours 
in the incubator. 




Fig. 43. — Diagrammatic representation of retraction of protoplasm, with produc- 
tion of pale points, in the bacillus of typhoid fever (Abbott). 

Morphology. — Medium-sized bacilli with rounded ends, 

1 Eberth: Virchow's Arch. f. Path. Anat., Bd. 81, 1880; Bd. S3, 1881 ; 
Gaffky : Mitth. a. d. Kais. Gesundheitsamte, Bd. 2, 1884. 



142 PATHOLOGICAL TECHNIQUE. 

generally short (Fig. 42), but sometimes long or thread-like, 
and frequently showing faintly-stained, sharply-defined areas 
in their protoplasm (Fig. 43). 

Gelatin Slant. — Broad translucent streak with wavy, 
irregular margins. The gelatin is not liquefied. Growth is 
slower than that of the bacillus coli communis in the same 
medium. 

An isolated colony, slightly magnified, on gelatin, is shown 
in Fig. 44. 

Glucose-gelatin Stab. — Growth all along the line of inocu- 
lation in the form of confluent spherical grayish colonies, and 




FlG. 44. — Bacillus of typhoid fever : superficial colony two days old, as seen 
upon the surface of a gelatin plate ; X 20 (Heim). 

on the surface about the point of entrance of the platinum 
wire in the form of a circular translucent grayish layer. No 
production of gas-bubbles. No liquefaction. 

Glucose Agar-agar. — Growth similar to that in the pre- 
ceding. No gas-formation. 

Litmus-milk. — No visible change. 

Potato. — Growth occurs, but it is usually invisible. 

Dunham's Pepton Solution. — No indol-production — i. e. 
no red color appearing in the twenty-four- to forty-eight- 
hour cultures after the addition of 5 drops of concentrated 
sulphuric acid, c. p., and 1 cubic centimeter of a solution of 
sodium nitrite, 1 : 10,000. 

Motility. — Very marked. 



BACTERIOLOGICAL EXAMINATIONS. 1 43 

Flagella (Fig. 45) may be demonstrated by the special 
methods of staining described elsewhere. 

Decolorized by Gram's method. Does not form spores. 

Bouillon. — -Clouded, with the formation of some sediment. 
The clouding of the medium is not so marked as in the case 
of the bacillus coli communis. In general, the growth of the 
typhoid organism is not so vigorous on culture-media as is 
the growth of the bacillus coli communis. 

When to a bouillon culture a small quantity of the blood- 



■ 






Si 



mm 



Fig. 45. — Bacillus of typhoid fever, from an agar-agar culture six hours oid, 
showing the flagella stained by Loffler's method ; X 1000 (Frankel and Pfeiffer). 



serum of a typhoid-fever patient is added, the bacilli lose 
their motility and aggregate in clumps (" serum reaction "). 

Pathogenesis. — The inoculation of animals is usually with- 
out results if moderate quantities of the organism are used. 
Sometimes, however, death occurs apparently from the 
effects of the toxic material injected. 

Occurrence. — Found in the spleen in large numbers at 
autopsies in typhoid fever. Its presence may also be demon- 
strated in the intestinal lesions, mesenteric lymph-glands, 
liver, bile, kidneys, and blood of the heart. As a rule, the 
number of bacilli found in the liver, kidneys, and blood of 



144 PATHOLOGICAL TECHNIQUE. 

the heart is small. In the bile they may be numerous and 
may persist in it for a long period of time after the disease 
has subsided. 

The typhoid bacillus may also occur in the suppurative 
sequelae of typhoid fever, especially those involving bones. 
In these conditions, however, it may be accompanied by the 
pyogenic cocci. Occurs in contaminated water. 

Differential Diagnosis between the Bacillus of Typhoid 
Fever and the Bacillus Coli Communis. — The most im- 
portant points of difference between these two organisms are 
as follows, and to distinguish with certainty between them it 
is necessary that attention be paid to all of them : 

Motility. — The -typhoid bacillus is actively motile, the 
bacillus coli communis not motile or exceptionally motile. 

Potato Cultures. — The typhoid bacillus usually grows in- 
visibly, the bacillus coli communis as a dirty, slimy layer. 

Gas-production in Media containing Glucose. — The bacillus 
coli communis produces gas, the typhoid bacillus does not. 

Litmus-milk Cultures. — The bacillus coli communis changes 
the blue color of the medium to a pink color and usually 
coagulates the milk. The typhoid bacillus produces no 
visible change. 

Indol-productio7t. — The bacillus coli communis produces 
indol, the typhoid bacillus does not. 

Serum or Clump Reaction. — The typhoid bacillus shows 
the clump reaction, while the bacillus coli communis does 
not. As it is not always possible to have a typhoid serum 
at hand by which to determine whether this reaction is 
present, a stock of dried blood from a typhoid case, con- 
tained in filter-paper, may be kept ready for use. That this 
is quite practicable has been recently shown by Dr. Mark W. 
Richardson. The blood may be obtained from the heart at 
the autopsy of a typhoid-fever case by soaking a piece of 
filter-paper with it. This is allowed to dry, and then is cut 
into pieces about I cm. square. When it is desired to make 
the test, one of these pieces is extracted with ten or fifteen 
drops of water, and a drop of this extract is mixed with a 
drop of an eighteen- to twenty-four-hour bouillon culture 



BACTERIOLOGICAL EXAMINATIONS. 1 45 

on a slide, covered with a cover-glass, and examined with 
the high-power dry lens. Dr. Richardson has found that 
the blood under these conditions retains for months its 
" clumping " power with reference to the typhoid bacillus. 

Other differences are — the production of a red color in 
litmus-lactose agar-agar by the bacillus coli communis, and 
no change in color of this medium by the typhoid bacillus, 
and the slower and less vigorous growth of the typhoid 
bacillus in culture-media. 

Bacillus Coli Communis. 1 — Synonyms : Bacterium coli 
commune ; Colon bacillus. 

Blood-serum. — Rounded, grayish-white, slightly elevated, 




FIG. 46. — Bacillus coli communis, from an agar-agar culture; x 1000 (Itzerott 

and Niemann). 

viscid-looking colonies, which may attain a diameter of 
3 mm. after twenty-four hours in the incubator. 

Morphology. — A medium-sized bacillus with rounded ends, 
often short or even coccus-like, but may grow in long 
forms (Fig. 46). Faintly staining, sharply defined areas are 
present in the protoplasm. 

Gelatin Slant. — Grayish translucent strip with wavy mar- 
gins. The gelatin is not liquefied. Growth is more rapid 
than in the case of the typhoid bacillus. 

1 Escherich: Fortschr. d. Medicin, 1885, Nos. 16, 17. 
10 



I46 PATHOLOGICAL TECHNIQUE. 

A single colony on a gelatin plate is shown in Fig. 47. 

Glucose-gelatin Stab. — Growth along the line of stab in 
the form of confluent spherical colonies, and on the surface 
about the point of entrance of the needle as a thin gray 
circular layer. Gas-bubbles are produced in the gelatin 
from fermentation of the glucose. The gelatin is not 
liquefied. 

Glucose-agar-agar Stab. — Growth essentially the same as 
in the preceding, except that the gas-formation is more 
marked. 

Litmus-milk. — Turned pink and usually coagulated. 




Fig. 47. — Bacillus coli communis : superficial colony two days old upon a gela- 
tin plate ; X 21 (Heim). 

Potato. — Dirty grayish or brownish, viscid-looking layer. 

Dunham's Pepton Solution. — Marked indol-production. 
This is shown by the appearance of a red color in the cul- 
ture after the addition of 5 drops of concentrated sulphuric 
acid, c. p., and 1 c.c. of a 1 : 10,000 solution of sodium 
nitrite. The culture in the pepton solution should have 
been at least twenty-four hours — or, better, forty-eight hours 
— in the incubator before the test is made. 

Motility. — Usually not motile, but some varieties show 
sluggish independent movement. 

Flagella. — May be demonstrated by the special methods 
of staining. They are less numerous than in the case of the 
typhoid bacillus. 



BACTERIOLOGICAL EXAMINATIONS. 1 47 

Decolorized by Gram's method. 

Bouillon. — Markedly clouded with formation of a sedi- 
ment. The clouding is more marked than in the case of the 
typhoid bacillus. 

Lactose-litmus-agar-agar Slant. — Growth has a pink color, 
and the blue color of the medium is changed to red. 

Pathogenesis. — " Its virulence as tested upon animals is 
variable, but is generally manifest only after inoculation of 
large doses, which kill by intoxication rather than infection " 
(Welch). 

The lesions produced are not sufficiently characteristic to 
be detailed here. 

Occurrence. — Occurs constantly in the intestinal canal, and 
is widely distributed in the external world. 

" The colon bacillus is a frequent invader of the internal 
organs in all sorts of diseases, especially when there are in- 
testinal lesions. It manifests no evident pathogenic action 
in most of these cases, and is then without clinical signif- 
icance. It occurs frequently associated with other bacteria 
in infected wounds and other inflammations of exposed sur- 
faces. Here also it does not usually appear to cause serious 
disturbance. The fact that the colon bacillus is so common 
and widely distributed, and found so often as a harmless in- 
vader, should lead to much caution in interpreting the sig- 
nificance of its presence when it occurs in definite lesions. 
There is no doubt, however, that it may be pathogenic for 
man. It plays an important role in inflammations of the 
urinary tract and biliary passages ; also, but usually with less 
independence, in peritonitis and appendicitis. 

" The list of diseases in which it may be found is a very 
long one and includes inflammations in all organs and parts 
of the body. In general its pathogenic properties are of a 
mild character. One of its leading roles is to invade terri- 
tory already occupied by other bacteria or previously 
damaged. It may be concerned in the production of gall- 
stones, in the interior of which it has been found by the 
writer with great frequency " (Welch, Dennis's System of 
Surgery, vol. i.). 



I48 PATHOLOGICAL TECHNIQUE. 

The bacillus above described is to be regarded as a type of a 
group of bacilli constituting the so-called "colon group" of 
bacilli. These present certain quantitative differences among 
themselves which are not quite sufficient to characterize them as 
distinct species. 

Welch regards as belonging to this group the Bacillus pyogenes 
foetidus (Fig. 48), distinguished by the stinking odor of its cul- 
tures, and the Bacillus lactis aerogenes, which is characterized 



*> • l ***** Vv* 



V 






% *r# 



f f .<*;•* %'' * * ^ ;% 



* ■ J % % 4 
1 v ' - * \ 1 * § 

'!**** * i r * *** * 

i • # **• ■* 

Fig. 48. — Bacillus pyogenes foetidus, from agar-agar; X i°°o (Itzerott and 

Niemann). 



chiefly by its plumper form, its more energetic gas-production, 
its rapid coagulation of milk, and its denser growth in cultures. 

Bacillus Tuberculosis. 1 ^- Synonyms : Tubercle bacillus ; 
Bacillus of Koch. (See also Clinical Bacteriology.) 

Blood-serum. — After three or four weeks in the incubator 
the colonies appear as dry, cream-colored, granular, slightly 
elevated patches with irregular margins, 1 to 2 mm. in diam- 
eter. They may become confluent, to form a dense dry, 
granular mass with irregular surface and of a creamy-white 
color. The growth is very friable, but coherent, and may 
be picked up in clumps on the platinum wire. The first 
generation from tissues is very slow in developing, but suc- 
ceeding generations grow more rapidly, and may form a 

1 Koch : Berlin, klin. Wochenschr., 1 882, No. 15 ; Mitth. a. d. Kais. Ge- 
sundheitsamte ; Bd. 2, 1884. 



BA CTERIOL GICAL EXAMINA TIONS. 



149 



wrinkled, dry, cream-colored membranous layer on the 
surface of the medium. 

Morphology, — Slender rods, usually shorter than when 
observed in sputum, and in fresh cultures staining homo- 
geneously; in older cultures presenting a segmented or 
irregularly stained appearance. They frequently occur in 
pairs of short rods and in closely adhering clumps and 
strands (Fig. 49). When once stained with fuchsin or gen- 
tian-violet they are not decolorized by treatment with Gab- 




Fig. 49. — Bacillus tuberculosis : cover-glass preparation from a fourteen-day-old 
blood-serum culture ; X 100 (Frankel and Pfeiffer). 

bet's solution or with a 20 per cent, solution of any of the 
mineral acids, followed by alcohol. 

Stained by Gram's method. Not motile. Does not form 
spores. 

Glycerin Agar-agar Slant. — Growth similar to that on 
blood-serum, but not so vigorous. By continued inoculation 
of this medium through a number of generations, however, 
the organism may eventually grow luxuriantly upon it. 

Glycerin Bouillon. — Growth on the surface in the farm of 
floating patches or as a membrane similar in appearance 
to the growth on blood-serum. The growth sinks to the 
bottom from time to time. The glycerin-bouillon culture is 



150 PATHOLOGICAL TECHNIQUE. 

best contained in Ehrlenmeyer flasks, filled to such a depth 
as to give a wide surface to the fluid and thus permit the 
access of plenty of oxygen to the growth. 

Potato.— The growth is not remarkable. 

Agar-agar or bouillon not containing glycerin is not suit- 
able for the cultivation of this bacillus. 

Pathogenesis. — The inoculation of guinea-pigs or rabbits by 
any method is followed by the development of general mili- 
ary tuberculosis. Guinea-pigs are most susceptible. These 
animals usually survive about two or three months, with 
marked emaciation. The lesions in the spleen and liver in 
the guinea-pig are characterized by extensive areas of ne- 
crosis not confined to the tubercular tissue, large parts of 
these organs being transformed into a firm yellow, opaque, 
friable material. 

Isolation of the Bacillus Tuberculosis from Tubercular Le- 
sions. — The best method of procedure is to inoculate a guinea- 
pig subcutaneously in the abdominal wall with tubercular 
material, and after four to six weeks, when the inguinal lym- 
phatic glands have become enlarged, to kill the animal. 
The object of killing the animal, rather than allowing it to 
die spontaneously, is to secure fresh tissue and to avoid the 
chance of an invasion of the lesions by other bacteria. 

Cultures on blood-serum are then to be made from the 
tuberculous lymphatic glands of the inguinal and retro- 
peritoneal regions of the animal. A number of tubes are 
to be inoculated, say three or four, from each of the two 
or three glands, a large quantity of material being spread 
upon the surface of each tube. Great care is to be exer- 
cised to avoid contamination with other bacteria in preparing 
these cultures. The culture-tubes used should contain freshly 
prepared moist medium, and immediately after inoculation 
should be sealed air-tight to prevent evaporation. This may 
conveniently be done by first cutting off the projecting por- 
tion of the cotton stopper and inserting a cork into the 
mouth of the tube in such a way as to push the cotton 
stopper before it. 

In order to prevent the invasion of fungi from the cotton, 



BACTERIOLOGICAL EXAMINATIONS. I 5 I 

the neck of the tube should be heated in the Bunsen flame 
until the cotton begins to brown before inserting the cork, 
which should also be charred in the Bunsen flame before in- 
sertion. The tubes may also be sealed with wax or paraffin 
or covered with small rubber caps. 

Cultures may also be made from other organs containing 
tubercular lesions, but the lymphatic glands seem to offer 
the best examples of large tubercular foci, and therefore are 
preferred for the purpose in view. 

The tubercular lesions in human tissues are not ordinarily 
favorable for the isolation of the bacillus, on account of the 
frequent presence of other bacteria in them and because of 
the small number of tubercle bacilli usually present in tissue 
otherwise suitable. 

We have found the firmly coagulated, opaque blood-serum 
medium above mentioned to be quite adequate for the cul- 
tivation of the bacillus from its lesions, both in man and 
guinea-pigs. 

A special culture-medium for the cultivation of the bacillus tu- 
berculosis is that recommended by Lubinski. Its composition and 
mode of preparation are as follows — to make one liter of medium : 

Take 1 kilo of potato in small pieces, and, after thoroughly 
washing, cook in the steam sterilizer for three or four hours with 
1500 c.c. of water. Of the mass thus formed take 1000 c.c., 
and add to it 500 grams of finely chopped beef, and allow it to 
stand in the cold for twenty-four hours, then boil the mixture for 
a few minutes and filter. Add to the filtrate 1 to 1.5 per cent, 
agar-agar, and boil until the agar-agar is thoroughly dissolved. 
This will require say half an hour's boiling. Next add 1 per cent, 
pepton and 0.5 per cent, sodium chlorid. When these are thor- 
oughly in solution, and after about five minutes' continued boiling, 
the mixture is to be neutralized with sodium hydrate solution, 
boiling meanwhile. When brought to the proper reaction it is to 
be filtered, and to the filtrate add 4 per cent, glycerin. The 
medium is then to be run into test-tubes and sterilized as in the 
case of agar-agar. The loss by evaporation in boiling is to be 
made up with water. 

A bouillon may be also made by leaving out the agar-agar. 

Another special culture-medium is that recommended by Ca- 
paldi. This consists in mixing with fluid agar-agar in tubes, at a 
temperature of 45 C, three or four large loopsful of the yelk 
of a fresh egg to each tube. When the portion of the yelk taken 
is thoroughly mixed with the fluid agar, the tube is placed on its 



152 PATHOLOGICAL TECHNIQUE. 

side, and its contents allowed to become solid by cooling so as 
to form a " slant." In securing the yelk aseptic precautions must 
be used. The egg must be quite fresh. By suitable manipulations 
the yelk is to be freed from the ''white " and placed in a small, 
clean dish. Then the yelk-membrane is to be seared with a hot 
knife and an opening made in it. Through this opening the yelk 
is obtained with the loop. Before using the culture-tubes so pre- 
pared, they should be tested as to their sterility by placing in the 
incubator for twenty-four hours. 

Occurrence. — In tubercular lesions generally and in the 
sputum of pulmonary phthisis, in the urine in many cases 
of genito-urinary tuberculosis, and in the feces in intestinal 
tuberculosis. The tuberculosis of cattle is generally con- 
sidered to be due to this organism, while the tuberculosis of 
birds is probably due to a different variety. 

Does not multiply outside of the body except in cultures. 

May occur on the surface of objects contaminated with 
the excreta of tuberculous individuals or in the dust of places 
inhabited by such individuals. 

Spirillum of Asiatic Cholera (Comma Bacillus) 1 
(see also Clinical Bacteriology). — Morphology (Figs. 50, 51). 
— In fresh cultures the organism appears usually as a slightly 
curved rod somewhat shorter than the tubercle bacillus, but 
much thicker. The curving of the rod varies, being very 
marked in some individuals and absent in others. Sometimes 
two rods are joined end to end with their convexity pointing 
in opposite directions, or moderately long, undulating threads 
may be found. It seems probable that the curved rods rep- 
resent the segments of a spirillum, and hence the name of 
the organism. 

In cultures some days old degenerated and atypical forms 
are found (involution forms). The organism is motile, and a 
single flagellum is attached to the end of the rod. 

It is not stained by Gram's method. 

Colonies on Gelatin Plates (Fig. 52). — After twenty-four to 
forty-eight hours at a temperature of 20 to 22 ° C. the 
largest colonies will appear as masses of indefinite granular 
material lying in circular areas of liquefied gelatin in which 

1 Koch : Deutsche vied. Wochenschr., 1884 and 1885. 



BACTERIOLOGICAL EXAMINATIONS. 1 53 

granular shreds are scattered. Within the next twenty-four 
hours the areas of liquefaction increase, and the colonies ap- 






* ZJ9, * *iMw c 






*- J S>v , 'ft*?!.* 









Fig. 50. — Spirillum of Asiatic cholera, from a bouillon culture three weeks old, 
showing long and degenerate forms ; X 1000 (Frankel and Pfeiffer). 

pear under the low power " as a dense granular mass sur- 
rounded by an area of liquefaction through which can be seen 



w* > 



/J -■ t . . V* 

Fig. 51. — Spirillum of Asiatic cholera, showing the flagella ; X 1000 (Giinther). 

granular prolongations of the colony, usually extending ir- 
regularly between the periphery and the central mass " (Ab- 



154 



PA THOL O GICA L TE CHNIQ UE. 



bott), while the margin of the liquefied area is marked by 
delicate radiating filaments closely packed together. 

The colonies on agar-agar plates are not characteristic. 
Growth is rapid. 

Gelatin Stab. — Growth all along the line of inoculation 
with liquefaction at the surface in funnel form after forty- 
eight hours. The liquefaction proceeds in such a manner 
that the liquefied area has a smaller diameter at the surface 
than immediately beneath, and, owing to the fact that the 
liquefied gelatin does not fill the cavity, a space is left be- 
tween the surface of the medium and the surface of the lique- 
fied gelatin so that the appearance of an air-bubble is pro- 



;?2 






Fig. 52. — Developmental stages of colonies of the spirillum of Asiatic cholera 
at 20 to 22 C. on gelatin ; x about 75 diameters (Abbott) : a, after sixteen to 
eighteen hours ; b, after twenty-four to twenty-six hours ; c, after thirty-eight to 
forty hours ; d, after forty-eight to fifty hours ; e, after sixty-four to seventy hours. 

duced. Along the deeper portions of the line of inoculation 
the liquefaction is slow. 

Bouillon. — Diffusely clouded. A thin pellicle forms on the 
surface after a time. 

Litmus-milk. — Turned red and coagulated. 

Indol-production. — In cultures in Dunham's pepton solu- 
tion or in the pepton solution of Koch (2 per cent, pepton 
and I per cent, sodium chlorid) a rose-color is produced by 
the addition of sulphuric acid alone. (Concentrated c. p. 
acid is to be employed, as in the test for indol-production by 
the bacillus coli communis.) The production of the rose-color 
without the addition of the sodium nitrite shows that nitrites 
as well as indol are formed by the growth of the organism 



BACTERIOLOGICAL EXAMINATIONS. 155 

in the pepton solution. The reaction can be obtained in 
cultures which have been but eight hours in the incubator. 

Potato. — Thin, dry, grayish-white growth which does not 
spread over the surface. 

Pathogenesis. — The pathogenic effects of the cholera 
spirillum are best shown by the inoculation of guinea-pigs. 
There are two methods of inoculation, as follows : 

1. The Method of Pfeiffer. — Scrape from the surface of a 
fresh agar-agar culture as much of the growth as will adhere 
to a platinum wire bent into the form of a small loop. Sus- 
pend this amount of material in 1 c.c. of bouillon, and inject 
the suspension into the peritoneal cavity of a guinea-pig 
by means of a hypodermic syringe. With virulent cultures 
this inoculation soon produces a fall in the temperature of 
the animal, which continues and becomes more marked, 
death occurring in from twelve to twenty-four hours. At 
the autopsy of the animal a clear fluid will be found in the 
peritoneal cavity and in the thorax. 

2. The Method of Koch. — This depends upon the fact that 
the animal may be infected through the alimentary canal, 
provided the acidity of the gastric juice be neutralized, this 
acidity being destructive to the cholera spirillum. 

A soft catheter is passed into the stomach of the animal 
through the mouth, and through this 5 c.c. of a 5 per cent, 
solution of sodium carbonate is injected. After ten or fifteen 
minutes 10 c.c. of a bouillon culture of the organism are in- 
jected through the catheter, and immediately afterward the 
animal receives subcutaneously 1 c.c. of the tincture of 
opium for every 200 grams of its body-weight. The object 
of this opium administration is to stop peristalsis, so that the 
organisms may be longer in contact with a given area of 
the mucous membrane of the intestine. The result of the 
inoculation first appears after about twenty-four hours. The 
animal then has no appetite and is listless. Later, paralysis 
of the hinder extremities appears, respiration is prolonged 
and weak, the heart-beats become feeble, and the body-tem- 
perature may become subnormal. Death usually occurs 
after the animal has been a few hours in this condition. 



156 ' PATHOLOGICAL TECHNIQUE. 

At the autopsy the small intestine will be found to be in- 
jected and containing a flocculent colorless fluid in which 
comma bacilli are present in great numbers. 

Occurrence. — In the alvine dejections and in the intestinal 
contents of cholera patients (Fig. 53). It apparently only 
rarely invades the circulating blood. Its presence in the 
vomitus may sometimes be shown. It has been found in the 
water-supplies during epidemics. 




*igr*-*^'^- 



Fig. 53. — Cover-glass preparation of a mucous floccule in Asiatic cholera; X 650 

(Vierordt). 

Bacillus of Anthrax l (see also Clinical Bacteriology). — 
Blood-serum. — Irregularly rounded colonies, several mm. in 
diameter after twenty-four hours in the incubator. The 
colonies are grayish, finely granular, and have the appear- 
ance of being made up of a dense network of delicate fibrillae. 
The blood-serum is slowly liquefied. 

Morphology. — The organism grows in long segmented 
threads, the segments varying in length, but usually being 
two or three times as long as broad and having square or 
slightly concave ends. These segments represent the bacillus, 
which is among the largest of the bacteria (Fig. 54). 

1 Pasteur : Bull. Acad, de Med., Paris, T. viii., 1879; Koch: F. Cohn's 
Beitr. z. Biol. d. PJl., Bd. 2, 1876. 



BA CTERIOL O GICAL EXAM1NA TIONS. 



157 




Fig. 54. — Bacillus of anthrax : portion of a colony three days old upon a gelatin 
plate ; X 1000 (Frankel and Pfeiffer). 

Pathogenesis. — Mice, guinea-pigs, and rabbits inoculated 
subcutaneously die with a general invasion of the blood by 



3 ^KW\ 



\ 



v& 



Sjr 



A 



\ 



*ar. \r\ e>. 







FIG. 55. — Bacillus of anthrax ; cover-glass preparation from spleen of a mouse. 

the organism. Mice are most susceptible to the infection, 
dying in about twenty-four hours, w T hile guinea-pigs and 



rabbits survive longer. 



158 PATHOLOGICAL TECHNIQUE. 

In all these animals the most striking lesion is a large soft 
spleen, and in the guinea-pig also an extensive inflammatory 
edema of the subcutaneous tissues. On microscopic exam- 
ination the bacilli will be found in the organs and blood of 
the heart. If the animal has been dead some time, the 
number of bacilli present in these situations will be very 
great, owing to the post-mortem growth. It is characteristic 
of the bacillus of anthrax in cover-slip preparations from in- 
fected tissues that it should have a narrow capsule (Fig. 55) 






* V V* 






\J* 






Fig. 56. — Bacillus of anthrax, stained to show the spores; X iooo (Frankel and 

Pfeiffer). 

and show square or slightly concave ends. The capsule is 
not present in cultures. 

Stained by Gram's method. Not motile. 

Forms oval spores in the middle of the short segments or 
rods. The spores may be seen in blood-serum cultures after 
forty-eight hours in the incubator (Fig. 56). 

Gelatin Stab. — Growth along the line of stab, with radiat- 
ing filaments extending laterally into the gelatin, which is 
slowly liquefied in funnel form (Fig. 57). 

Bouillon. — Growth in the form of cotton-like flakes and 
filamentous masses. No clouding of the medium. 

Agar-agar. — Matted network of translucent filaments. 



BA CTERIOL O GICAL EXAM IN A TIONS. 



*59 



Under a lower magnifying power the growth is seen to be 
made up of twisted and contorted masses of filaments, giv- 
ing the appearance of curled hair (Fig. 58). 




FIG. 57. — Bacillus of anthrax : gelatin stab-culture seven days old (Giinther). 

Potato. — Grayish-white, rather thick, dry layer, having the 
appearance of frosted glass. 

Occurrence. — In malignant pustule, wool-sorter's disease, 




Fig. 58. — Colony of bacillus of anthrax, slightly magnified (Fliigge). 

and intestinal anthrax. Found in the blood of animals dead 
of anthrax. In man the infection is usually localized at 



l6o PATHOLOGICAL TECHNIQUE. 

first at the point of inoculation, either on the skin or on the 
mucous membrane of the air-passages or intestinal tract. 
Later, a general invasion of the blood may occur and a fatal 
septicemia result. The organism or its spores may be pres- 
ent in wool or hides, and infection may take place from these. 

Bacillus Pyocyaneus (Bacillus of Green Pus). 1 — 
Colonies on blood-serum grow rapidly, are not especially 
characteristic in form, and liquefy the medium, imparting to 
it a dark greenish color. 

Morphology. — Small bacilli with rounded ends (Fig. 59). 

Fig. 59. — Bacillus pyocyaneus, from an agar-agar culture; X iooo (Itzerott and 

Niemann). 

Decolorized by Gram's method (Welch). Motile, and is 
provided with a flagellum at one end. Does not form spores. 

Gelatin Stab. — Liquefaction in funnel form, with green 
fluorescence of the upper portions of the medium. The 
liquefied gelatin is densely clouded, and there may be a 
viscid pellicle on the surface. 

Agar-agar Stab. — A green fluorescence in the upper layers 
of the medium, which later becomes a dark blue-green. 

Potato.— Slightly elevated, brownish, viscid layer. The 
potato in some cases assumes a green color, in others a 
brown color. In some cultures the potato when touched 

1 Gessard : Annates de V Institut Pasteur, T. 5, 1891. 



BACTERIOLOGICAL EXAMINATIONS. l6l 

with the platinum wire takes on a green color at the point 
touched. This is the so-called " chameleon phenomenon," 
and it is best observed in cultures several days old. 

Bouillon. — The growth is in the form of flocculi and a 
delicate surface pellicle. The fluid acquires a green color. 

Litmus-milk. — Acid reaction with coagulation. 

Dunham' s Pepton Solution. — Indol is produced. 

Colonies on Gelatin Plates (Fig. 60). — Development is rapid. 
"Young colonies are provided with a fringe of delicate fila- 




f^r\)--^;g§§M 


iE*-^;':'-' ' ■ ",' 


'"" ? ^ 




fiWfc" 




v ■----■-, 


t- - ' '-. - 


"• -vV'>- 


wmm 




fp 


^<toX& 


1 :■'■ '■ v ': .•' ' / 





FIG. 60. — Bacillus pyocyaneus : colonies upon gelatin (Abbott). 

ments about their periphery. ... As growth progresses and 
liquefaction becomes more advanced, the central mass of the 
colony sinks into the liquefied depression, while at the same 
time there is an extension of the colony laterally. ... At this 
stage the colony, when slightly magnified, may present vari- 
ous appearances, the most common being that shown in Fig. 
60. The gelatin between the growing colonies takes on a 
bright yellowish-green color, but, as growth is comparatively 
rapid, it is quickly entirely liquefied, and one often sees the 
colonies floating about in the pale-green fluid." x 

Pathogenesis. — Subcutaneous inoculation of guinea-pigs 
and rabbits with 1 c.c. of a virulent bouillon culture may 
produce purulent infiltration and inflammatory edema of the 
tissue about the point of inoculation, and death may follow 
in eighteen to thirty-six hours. Intraperitoneal inoculation 

1 Abbott : Principles of Bacteriology. 
11 



1 62 PATHOLOGICAL TECHNIQUE. 

may result in a serofibrinous or purulent peritonitis with 
fatal result. In fatal inoculations the bacillus is found in the 
various viscera, but not in great numbers. Animals inocu- 
lated with small amounts may survive with merely local 
lesions, and an immunity may be produced. 

Several varieties of this bacillus have been described, but their 
differences do not seem to be of sufficient importance to justify 
their separation into distinct species. 

Occurrence. — " Is widely distributed, occurring often on the 
human skin, in the feces, and outside of the body. In wounds, 
stains the dressings bluish-green and produces a somewhat 
characteristic offensive odor. 

" Increases suppuration of wounds, usually with little con- 
stitutional disturbance. Is found not infrequently in perfora- 
tive peritonitis and appendicitis, sometimes in phlegmons, 
otitis media, broncho-pneumonia, and inflammation of serous 
membranes, associated usually with other bacteria. 

" It was found by H. C. Ernst in tuberculous pericarditis. 
Often found in diarrheal and dysenteric discharges. May 
cause general infection in human beings. With or without 
general infection it may cause hemorrhagic and necrotic en- 
teritis, a form of pyocyaneous infection in human beings which 
we have repeatedly observed at autopsy. Instances of in- 
vasion of the body from wounds by the bacillus pyocyaneus 
have not been observed " (Welch). 

Bacillus of Influenza l (see also Clinical Bacteriology). 
— Morplwlogy. — Very small bacilli, with rounded ends and 
of variable length, sometimes growing into long forms, more 
or less bent or curved. 

Stains more deeply at the ends than in the middle, and in 
the long forms shows irregularity of staining. The faintly 
stained areas are very sharply defined, as in the case of the 
typhoid bacillus. 

Cultivation. — Does not grow in the ordinary culture-media, 
but maybe cultivated on agar- agar " slants," the surfaces 
of which have been smeared with a few drops of sterile 

1 Pfeiffer: Zeitschrift f. Hygiene u. Infectionskrankheiten, Bd. 13, 1893. 



BACTERIOLOGICAL EXAMINATIONS. 1 63 

blood. The blood of man, rabbits, guinea-pigs, pigeons, or 
frogs will serve for this purpose, the best growth being 
obtained with pigeon's blood. The blood may be ob- 
tained from a needle-prick, and spread over the surface 
of the agar-agar by means of the platinum loop. The skin 
should be previously thoroughly washed with alcohol and 
ether, and the first drops of blood should not be used. 
Human blood is best obtained from the lobe of the ear 




Fig. 61.— Bacillus of influenza: colonies on blood agar-agar; low magnifying 
power (Pfeiffer). 

or from the finger. Tubes thus prepared are only rarely 
contaminated. 

Colonies. — After twenty-four hours in the incubator the 
colonies appear as minute colorless, glassy, transparent 
points resembling small drops of dew. They never attain 
any size, and do not become confluent. They are barely 
visible to the unpractised eye, and require a low magnifying 
power to be seen clearly. Under the low magnifying power 
they are translucent, homogeneous, not granular, and cir- 
cular in outline (Fig. 61). 



164 PATHOLOGICAL TECHNIQUE. 

Decolorized by Gram's method. Not motile. Will not 
grow without oxygen. 

Pathogenesis. — The ordinary laboratory animals are not 
susceptible to infection with this organism. 

Occurrence. — Found in the exudate of the respiratory tract 
in influenza, frequently inside of leucocytes (Fig. 62). It 
may be present in the small bronchi and in the exudate of 
broncho-pneumonia in this disease, sometimes unaccompanied 










I 




FlG. 62. — Bacillus of influenza: cover-glass preparation of sputum from a case 
of influenza, showing the bacilli in leucocytes; highly magnified (Pfeiffer). 

by other organisms. It has been observed in purulent 
meningitis secondary to influenza. 

Bacillus of Glanders (Bacillus Mallei). 1 — Blood- 
serum. — Rounded, elevated, colorless, viscid-looking colonies, 
growing slowly and becoming well developed after thirty-six 
hours in the incubator. They may attain a diameter of 2 or 
3 mm., and after a time they assume a brownish tint. 

Morphology. — Bacilli of medium size, variable in length, 
having rounded ends, and frequently showing faintly stained 
areas in their protoplasm (Fig. 63). The larger forms of the 

1 Loftier: Arbeilen a. d. Kais. Gesandheitsamte, Bd. I, 1886. 



BACTERIOLOGICAL EXAMINATIONS. 1 65 

bacillus are usually slightly bent or wavy in outline, and may 
be slightly swollen at their ends. 

Potato. — After thirty-six hours in the incubator a rather 
thick, colorless, viscid-looking layer appears, which soon 
assumes a brownish tint and resembles honey in appearance. 
Later the brown color changes to a dark reddish-brown, and 
the growth becomes thicker and more opaque, while the 
potato takes on a dark-gray color. 

Pathogenesis. — When inoculated subcutaneously into 






N . -■;., ^ *-"*s: f» 



Mz 



»"> 






^ 






FIG. 63. — Baccillus mallei, from a culture upon glycerin agar-agar; x 1000 
(Frankeland Pfeiffer). 

guinea-pigs the characteristic result is swelling and inflam- 
mation of the scrotum, appearing after a variable number of 
days, often about a week. 

The animals usually survive several weeks, with ulceration 
at the point of inoculation. The lesions produced consist 
in suppurative processes or abscess-formations in or about 
the testes, in the lymph-glands, in the anterior nares, about 
the joints, and in other situations, besides small grayish nod- 
ules or areas in the viscera — the so-called " glanders tuber- 
cles." The suprarenal capsules usually show red areas, and 
they may be enlarged. On microscopic examination, the 
small nodules as well as the extensive suppurative areas 



1 66 PATHOLOGICAL TECHNIQUE. 

will be found to be composed of necrotic material containing 
leucocytes and fragments of chromatin. The distribution and 
extent of the lesions vary with each animal, but the involve- 
ment of the testis or its membranes is practically constant 
and pathognomonic of the bacillus of glanders. This in- 
volvement of the testis may consist, in early cases, in the 
presence of yellow foci in or about the tunica vaginalis, or 
in later cases the organ may show large yellow areas with 
purulent softening. 

Intraperitoneal inoculation with virulent cultures may be 
followed by death within forty-eight hours, with fibrinous 
exudate on the peritoneum in which minute grayish nodules 
are seen. The nodules are made up of a material which is 
apparently mainly dead or degenerated leucocytes and des- 
quamated peritoneal endothelium, together with many chro- 
matin fragments. 

In these acute cases also microscopical examination of 
the spleen and liver may show the presence of small nodules 
identical in structure with those seen in the more chronic 
cases. For the purpose of producing with cultures the 
characteristic lesions of the testis or its coverings it is better 
to inoculate the animal subcutaneously, for in the rapidly 
fatal intraperitoneal inoculations with virulent cultures these 
may not show any marked changes. 

The bacilli may be cultivated from the lesions, but not 
from the blood of the heart, in the chronic cases. They 
may be present in the blood of the heart, however, in small 
numbers in rapidly fatal infections following intraperitoneal 
inoculation. 

Field-mice may die from subcutaneous inoculation in 
about seventy-two hours. The most conspicuous lesion 
produced is enlargement of the spleen, with the presence in 
it of minute grayish nodules. White mice are immune. 
Rabbits are not so susceptible as guinea-pigs to the infection. 

Decolorized by Gram's method. Not motile. Spore- 
formation not probable. Rate of growth is slow. 

Bouillon. — Diffusely clouded, with the formation of a vis- 
cid sediment. 



BACTERIOLOGICAL EXAMINATIONS. 1 67 

Litmus-milk. — Gradually turned red and coagulated. 

Agar-agar and Gelatin. — Growth not especially charac- 
teristic. 

Occurrence. — Found in the lesions of glanders, and may 
invade the blood-stream in small numbers in acute cases of 
infection. Grows in the tissues in clumps or groups as well 
as scattered. In lesions on exposed surfaces it may be ac- 
companied by the pyogenic cocci. 

Bacillus Proteus (Proteus Vulgaris). — Morphology. — 
Bacilli of very variable length, sometimes appearing like 
cocci or as filaments. 

Motile, being provided with terminal flagella. Does not 
stain by Gram's method. 

Colonies in Gelatin. — Rapid growth with liquefaction of 
the gelatin. In a medium containing 5 per cent, instead of 
10 per cent., of gelatin prolongations from the margins of 
the colonies may be formed. These may become sep- 
arated from the mother colonies and form daughter 
colonies. Motions may be observed in these prolonga- 
tions. 

Gelatin Stab. — Rapid liquefaction along the line of inocu- 
lation with cloudiness of the liquefied gelatin and a floccu- 
lent deposit. 

Agar-agar Slant. — Widely spreading, thin, moist, grayish- 
white layer. 

Potato. — Dirty white, moist layer. 

Litmus-milk. — Turned pink and slowly coagulated. 

Odor. — The cultures generally have a putrefactive odor. 

Pathogenesis. — Intravenous,, intraperitoneal, or intramus- 
cular inoculations of rabbits may produce death in twenty- 
four to thirty-six hours after moderately large doses. Liq- 
uefied gelatin-cultures are said to be more virulent than 
bouillon cultures. Guinea-pigs seem to be less susceptible 
than rabbits to infection with this organism. 

Occurrence. — This bacillus and its varieties are among the 
most common and widely distributed putrefactive bacteria. 
It occurs in the intestinal contents. In pathological exam- 
inations it may be found in peritonitis and in abscesses, 



i68 



PA THOL O GICA L TE CHNIQ UE. 



usually associated with other bacteria. It may also invade 
the circulating blood. 

The so-called " proteus group" includes several varieties of 
similar organisms — viz. the proteus vulgaris, the proteus mirabilis, 
and the proteus Zenkeri. The latter does not liquefy the gelatin, 
while the proteits mirabilis liquefies it slowly. 

Bacillus MUCOSUS CapSUlatUS. 1 — Blood-serum. — After 
twenty-four to thirty-six hours in the incubator the colonies 
appear as translucent, colorless, rounded, convex elevations, 




Fig. 64. — Bacillus mucosus capsulatus, from the sputum of a pneumonia 
patient; x 1000 (Frankel and Pfeiffer). 



resembling drops of mucus. If few in number, they may 
attain a diameter of 2-3 mm. They are viscid, and when 
touched with the platinum wire may be drawn out into 
threads. The water of condensation may become thick or 
viscid from the growth of the organism in it. 

Morphology. — Bacilli of moderate size, usually two or 
three times as long as broad, with rounded ends, occurring 
frequently in pairs and sometimes in long forms. Occasion- 
ally in cultures it shows a wide capsule. The capsule, how- 

1 Friedlander : Fortschritte der Medicin, 1883, Bd. I. S. 715; C. Fricke : 

Zeitschrift f. Hygiene it. Infectionskrankheiten, Bd. 23, 1896. 



BACTERIOLOGICAL EXAMINATIONS. 1 69 

ever, is best shown in cover-glass preparations from infected 
tissues (Figs. 64, 65). 

Pathogenesis. — White mice, rabbits, and guinea-pigs die 
from septicemia in a short time after inoculation, the capsule 
bacilli being present in the organs and blood of the heart in 
large numbers. 

White mice die in twenty-four hours to three days. Rab- 
bits inoculated in the ear-vein and guinea-pigs inoculated in 
the peritoneal cavity may die within twenty-four hours. 

Subcutaneous inoculation of the animals last named 




Fig. 65. — Bacillus mucosus capsulatus in blood; X 1000 (Frankel and Pfeiffer). 

leads only to local suppuration. The lesions produced by 
this organism consist in marked congestion of the super- 
ficial veins, hemorrhage into the lymphatic glands, and en- 
largement and softening of the spleen. In the guinea-pig a 
hemorrhagic condition of the supra-renal capsules is present, 
and in the peritoneal cavity there may be a small amount 
of clear, rather viscid fluid containing the bacilli in large 
numbers. 

The organs on microscopic examination may show pecu- 
liar areas in which the cells and nuclei are shrunken and in 
which the bacilli are aggregated. 



170 PATHOLOGICAL TECHNIQUE. 

Decolorized by Gram's method. Not motile. Does not 
form spores. 

Glucose Agar-agar Stab. — Growth along the line of inocu- 
lation, with the production of a few gas-bubbles in the medium. 

Bouillon. — Clouded with the formation of a thin pellicle. 

Potato. — Thin, colorless, viscid layer. 

Litmus-milk. — Turned red and coagulated. 

Gelatin. — Growth not remarkable. 

There apparently exists a number of varieties of aerobic capsu- 
lated bacilli differing from one another only in non-essential par- 
ticulars. The organism here described is to be taken as a type of 
a group of closely- related bacteria of which the bacillus pneu- 
monia of Friedlander is a well-known member. 

Occurrence. — This organism or closely related forms may 
be met with in broncho- or lobular pneumonia and in inflam- 



x 






/ 



i 



* , s 



t 



y 



Fig. 66. — Bacillus of tetanus; X 1000 (Frankel and Pfeiffer). 

matory conditions of the air-passages generally. It may 
also be present in the upper air-passages of healthy individ- 
uals. It has been observed in inflammations of the middle 
ear, in empyema, meningitis, endocarditis, peritonitis, and in 
pus-formations. In fatal infections the blood-stream may be 
found invaded by the organism. It is held by some bacteri- 
ologists that the members of this group may be the infective 
agents in genuine croupous pneumonia in rare instances. 



BA CTERIOL O GICAL EXAMINA TIONS. 



171 



Representatives of this group have been found in the soil, in 
the air, and in contaminated water. 

Bacillus of Tetanus. 1 — This bacillus will not grow in 
the presence of oxygen. 

Morphology. — Slender rods with rounded ends, which may 
grow into long threads. In the incubator spores are rapidly 
formed. These are round, wider than the bacillus, and are 








Fig. 67. — Bacillus of tetanus : ecu 
onies four days old in glucose-gelatin 
(Frankel and Pfeiffer). 



Fig. 68. — Bacillus of tetanus : six- 
days-old stab-culture in glucose-gelatin 
(Frankel and Pfeiffer). 



situated at the end of the rod, giving the appearance of a 
drum-stick or a round-headed pin (Fig. 66). 

The colonies in anaerobic glucose-gelatin cultures appear 
after several days as small clumps of interlacing fibrillar from 
which delicate filaments radiate into the gelatin, which is 
slowly liquefied (Figs. 67, 69). 

1 Kitasato : Zeitschrift f. Hygiene u. Infectionskrankheiten, Bd. 7, 1 889. 



1/2 PATHOLOGICAL TECHNIQUE. 

Pathogenesis. — Subcutaneous inoculation of mice at the 
root of the tail gives rise to tetanic symptoms in twenty- 
four hours, followed by death in two or three days. 

Guinea-pigs and rabbits are also susceptible to the infec- 
tion, the period of incubation in these animals being twenty- 
four to thirty hours in the former and two to three days in 
the latter animal, after subcutaneous inoculation. The symp- 
toms of tetanus appear first in the extremities nearest the 
point of inoculation. In mice the hind legs become rigidly 







FIG. 69. — Bacillus of tetanus : five-days-old colony in glucose-gelatin ; X 1000 
(Frankel and Pfeiffer). 



extended backward. At the autopsy the bacillus is to be 
found only at the point of inoculation, and may be difficult 
or impossible to demonstrate there. 

Glucose-gelatin Stab. — Growth along the line of inocula- 
tion, beginning 2 or 3 cm. below the surface, with delicate 
filaments radiating laterally into the gelatin (Fig. 6&). Liq- 
uefaction and gas-production occur. 

In the vegetative forms the organism is sluggishly motile. 
Stained by Gram's method. 



BACTERIOLOGICAL EXAMINATIONS. 1 73 

In anaerobic cultures in glucose-agar-agar and in glucose- 
bouillon growth is good, but is not remarkable. 

Occurrence. — Found in the soil, and often in the feces of 
herbivorous animals. In cases of tetanus the bacillus is to 
be found only in the wound or at the point of inoculation. 
It does not invade the blood-current. 

The bacillus of tetanus acts by the production of a " toxin " 
or " toxalbnmin." This is also produced in cultures. It may 
be demonstrated in the bacteria-free filtrate of bouillon cul- 
tures some days or weeks old. A very few drops of this 
fluid will give rise to fatal tetanus in a mouse. 

Bacillus Aerogenes Capsulatus. 1 — Will not grow in 
the presence of oxygen. 

Morphology. — Bacilli of about the thickness of the anthrax 
bacillus, variable in length, but usually 3 to 6/x long. Ends 
rounded or square cut. Occurs singly, in pairs, in clumps, 
and sometimes in short chains, less frequently in threads 
and long chains. 

May show unstained spots or deeply staining granules in 
the protoplasm. Capsules may be frequently demonstrated 
in the specimens from the tissues, and sometimes in agar- 
agar cultures. 

Colonies in anaerobic cultures are grayish to brownish- 
white, with a central darker spot by transmitted light. In 
time they may attain a diameter of 2 to 3 mm. or more. 
Colonies in the depths are spherical or oval, sometimes pre- 
senting knob-like or feathery projections. 

Effects on Animal Tissues. — Not pathogenic for rabbits. 

If a rabbit that has received 0.5 to 1 c.c. of a bouillon 
culture injected into the ear-vein be killed immediately after- 
ward and the body kept for twenty-four hours at a tempera- 
ture of 1 8° to 20 C, or for four to six hours at a tempera- 
ture of 30 to 35 C, the vessels and organs will be found 
to contain a great quantity of gas and large numbers of the 
bacilli. The organism multiplies post-mortem in the blood 
of the animal and produces the gas. This effect upon the 
tissues of the dead animal is characteristic of the bacillus. 

1 Welch and Flexner : Journal of Experim. Medicine, vol. i. No. 1, 1896. 



l 74 



PA THOL O GICA L TE CHNIQ UE. 



Gas-production is marked in agar-agar and gelatin cultures 
containing glucose. The gas produced burns with a blue 
flame and is odorless. 

Gelatin is liquefied slowly and to a limited extent. 

Glucose Bouillon. — Diffusely clouded at first, later becom- 
ing clearer, with an abundant whitish, more or less viscid 
sediment. 

Milk. — Coagulated, the clot being firm, retracted, and fur- 
rowed with the marks of gas-bubbles. 




Fig. 70. — Bacillus of malignant edema from the edema fluid of a guinea-pig 
inoculated with garden-earth ; X 1000 (Frankel and Pfeiffer). 



Potato. — Growth thin, moist, and grayish-white, or it may 
not be visible. 

The bacillus is stained by Gram's method. It does not 
form spores. 

The vitality of the organism depends upon the character 
of the culture-medium and the mode of cultivation. It sur- 
vives longer when cultivated by Buchner's method (see 
page 119) than when cultivated under hydrogen. Cul- 
tures on glucose media are shorter lived than those on 
plain media. 

Occurrence. — Occurs at autopsies in which gas-bubbles are 
present in the larger vessels, accompanied by the formation 



BA CTERIOL O GICA L EXAMINA TIONS. 



175 



of numerous small cavities in the liver containing gas. It 
has been found also in emphysematous phlegmons, in puer- 
peral sepsis, in peritonitis, and in other conditions. 

Bacillus of Malignant Edema. 1 — This bacillus will 
not grow in the presence of oxygen. 

Morphology. — Rather large bacilli, sometimes growing into 
threads (Fig. 70), but occurring frequently in pairs, in which 
the proximal ends are square while the distal ends are 
rounded. Forms oval spores in 
the middle of the rod, which may 
give the rod a spindle or oval 
shape. 

The colonies in anaerobic glu- 
cose-gelatin cultures appear as 
spheres of cloudy liquefied gela- 
tin marked by delicate radiating 
streaks. Gas-bubbles are formed 
in the medium (Fig. 71). 

Pathogenesis. — Subcutaneous in- 
oculation of mice, guinea-pigs, and 
rabbits is followed by death in from 
sixteen to forty-eight hours, de- 
pending upon the animal, mice 
being most susceptible. The 
typical lesions are extensive sub- 
cutaneous edema containing gas- 
bubbles and more or less blood, 
and enlargement of the spleen. 
The bacilli are found in the 
edema, in the viscera, and on the 
serous surfaces of the organs, but 
not in the blood of the heart if 
the examination be made imme- 
diately after death, except sometimes in mice. The organism 
is not capable of multiplying in the living blood, owing to 
the presence of oxygen. In inoculating subcutaneously a 
deep pocket should be made in the skin, and the material 

1 Liborius : Zeitschrift f. Hygiene u. Infectionskrankheiten, Bd. I, 1886. 




Fig. 71. — Bacillus of malig- 
nant edema ; colonies growing 
in glucose-gelatin (Frankel and 
PfeifferV 



I76 PATHOLOGICAL TECHNIQUE. 

for inoculation introduced into the tissue as far away from 
the opening as possible. This is to prevent the access of 
too much oxygen to the organism. 

Slightly motile. Flagella may be demonstrated by special 
staining methods. 

Decolorized by Gram's method. 

Growth in anaerobic agar-agar and bouillon culture is good, 
but not characteristic. 

Occurrence. — Widely distributed in the soil and in putre- 
fying substances. Only a very few cases are on record of 
infection in man by this bacillus. 

Actinomyces (Fig. 72). — The position of this organism 
among the other bacteria is not yet definitely settled, owing 
to its peculiar morphology, described below. The general 
tendency of late has been to classify it as a cladothrix. A 
number of varieties of actinomycetes is claimed, but only 
the probably identical variety affecting cattle and man is 
considered here. 

Morphology. — In tissues the organism appears as discrete 
and very characteristic colonies, less often as loose or com- 
pact tangles of branching filaments or as bacilli and cocci. 
The colonies are often large enough to be visible to the 
naked eye. In form they are spherical, oval, or slightly 
curved ; in color, gray and gelatinous, opaque white, yellow, 
or even brown. Occasionally they have a greenish tint. 

Cover-slip preparations from actively growing colonies in 
tissues show cocci, long and short bacilli, and single and 
branching filaments, of which some stain uniformly, while 
others consist of longer or shorter joints, each of which 
corresponds to a coccus or to a bacillus. Transparent club- 
shaped bodies, in which bacilli and cocci similar to those in 
the threads can often be found, are also present. 

Sections of colonies in the tissues show that they are solid 
or hollow, depending somewhat on their size. Around the 
outside is a layer of transparent bodies, the so-called " clubs " 
(Fig. 72). Inside of this layer is a thick tangle of branching 
filaments composed of bacilli and cocci. In the centers of 
the large colonies usually only a few threads are found. 



BA CTERIOL O GICAL EXAMINA TIONS. 



177 



Besides the colonies, careful examination of the tissue often 
shows numerous bacilli and filaments lying in or between the 
cells. The filaments may form closely-woven tangles sug- 
gesting colonies, or may spread out loosely in every direction. 

In cattle the organism appears most frequently as discrete 
colonies with marked development of the clubs, and as 
bacilli in and between the cells. In man this polymorphous 
bacterium seems to grow more luxuriantly ; discrete colonies 
with typical formation of clubs are often hard to find, while 
bacilli and loosely or closely-woven tangles of filaments are 
very abundant. 

The transparent clubs, which lie in the peripheries of the 



m$Mm 











Fig. 72. — Actinomyces (von Jaksch). 



colonies and form the characteristic peculiarity of the organ- 
ism, are due to a hyaline degeneration or swelling of the 
membrane or sheath of the bacilli and filaments under con- 
ditions which oppose their free growth. 

In cultures the organism appears as straight and curved 
rods of varying length and breadth, and on special media 
as straight, wavy, or spiral filaments which are often dichot- 
omously divided. No clubs are ever formed in artificial 
culture-media. 

Cultures. — The organism is anaerobic, but not strictly so, 
and grows slowly on agar-agar or blood-serum and in raw 
or boiled hen's or pigeon's eggs. On agar-agar and blood- 
serum it appears in the form of dry, discrete colonies which 
12 



178 PATHOLOGICAL TECHNIQUE. 

send roots into the culture-medium. The older colonies are 
often yellowish in color. Microscopically, the colonies con- 
sist mainly of bacilli. In eggs a tangle of threads is the 
commonest form. 

Pathogenesis. — The organism is extremely disappointing 
from the experimental standpoint, because of its very slight 
pathogenesis when cultures are inoculated into animals. 
Only a few observers, of whom Wolff and Israel are the 
most prominent, claim to have obtained positive results. By 
inoculating rabbits and guinea-pigs intraperitoneally with 
anaerobic cultures they succeeded in producing typical 
colonies with formation of clubs. 1 

For staining cover-slip preparations Gram's method is the 
most satisfactory. Partial decolorization in alcohol leaves 
the clubs lightly stained, while the filaments, etc. are stained 
intensely. 

The methods of staining sections of colonies in tissues are 
described elsewhere. 



VI. CLINICAL BACTERIOLOGY. 

General Considerations. — The end in view in the bac- 
teriological examination of pathological material obtained 
from the individual during life is the determination of the 
species of bacteria which may be present in it. The exam- 
ination is effected by various methods of cover-glass prepara- 
tion, of culture, and of animal inoculation. In this work it 
is of obvious importance that the material be protected from 
the invasion of bacteria from without, and that in its collec- 
tion every object with which it comes in contact be free from 
living bacteria. 

To fulfil these requirements the material may be conve- 
niently collected in any of the following ways : 

1. It may be obtained directly from the individual by 

1 Bostroem : " Untersuchungen uber die Aktinomykose des Menschen," 
Ziegler's Beitrage, z. path. Anat., vol. ix. pp. 1-240; M. Wolff and J. Israel: 
Virchow's Archiv f. path. Anat., vol. cxxvi. pp. n-58. 



BA CTERIOL O GICAL EXAMINA TIONS. 



79 





means of the sterilized platinum wire, and cover-glass prep- 
arations, cultures, and, if necessary, animal inoculations, 
made at once. 

2. Since a very small quantity of the material usually suf- 
fices for the purposes of examination, it may often be very 
conveniently collected and brought to 
the laboratory on the so-called" swabs," 
where it can be subjected to the vari- 
ous manipulations at leisure. 

The " swab " consists of a piece of 
rather stiff wire about six inches long, 
on one end of which is firmly twisted 
a pledget of absorbent cotton, so that 
the end of the wire is well covered. 
This is placed, cotton end first, in a 
test-tube, which is then provided with 
a cotton stopper (Fig. 73), and the 
whole sterilized in a hot-air sterilizer 
by heating to 150 to 180 C. during 
about half an hour. A large number 
of " swabs " in test-tubes may be kept 
on hand sterilized and ready for use. 

When it is desired to secure material 
for bacteriological examination on a 
" swab," the cotton stopper is removed, 
the swab taken out, and the cotton end 
brought in contact with the pus or 
exudate in such a manner that some 
adheres to the cotton. The swab is 
then immediately replaced in the test- 
tube, the cotton stopper returned to its 
place, and the whole then carried to 
the laboratory. 

In these manipulations care should be taken to avoid 
touching with the swab anything but the material which it 
is desired to examine, otherwise the material may be con- 
taminated with other bacteria than those originally present 
in it. 



Fig. 73.— Sterilized test- 
tube and swab for collect- 
ing pus and fluids for bac- 
teriological examinations 
(Warren). 



l8o PATHOLOGICAL TECHNIQUE. 

By means of swabs material for examination from pus or 
exudates may be secured and brought to the laboratory in 
most instances. They are especially useful in surgical work, 
in which it is often desirable to determine the character of 
the organism present in a pus-formation or exudation with- 
out waiting to summon a bacteriologist or to collect the 
necessary cover-glasses, culture-tubes, platinum needle, etc. 
The swabs and their test-tubes may be kept on hand in a 
sterile condition, so that they may be handled by the ope- 
rator or an assistant. 

3. Fluid material may be collected by aspiration or other- 
wise. In the case of fluids care should be taken that every- 
thing with which the fluid comes in contact be clean and 
sterilized by heat if possible. The use of antiseptics, 
such as carbolic acid or corrosive sublimate, is to be 
avoided. 

If a hypodermic syringe is used in obtaining material, it 
should be of a construction which will admit of sterilization 
by heat, and it should be so sterilized before using. 

Cover-glass Examinations. — For methods of preparation 
and staining see page 89. The cover-glass examination is 
of great importance, for it may give valuable information, 
not only as to the species, but also as to the number of bac- 
teria present. 

Preparation of Cultures. — The best culture-medium for 
general purposes is, we think, the coagulated blood-serum 
described elsewhere. In certain instances other special 
media are to be used, as will be pointed out in the following 
pages. In the preparation of cultures the same general di- 
rections given on page 94 are to be followed. 

If the material is on a " swab," the surface of the blood- 
serum or other media may be conveniently inoculated directly 
by gently rubbing the swab over it. In this case it is usually 
best to make a dilution or two by means of the platinum wire, 
as described on page 95, especially if there be a large amount 
of material on the swab or if the cover-glass examination 
has shown that a large number of bacteria are present. In 
any case it is important that the infected material be spread 



BACTERIOLOGICAL EXAMINATIONS. l8l 

over all of the surface of the medium, and not in the form 
of one or two narrow streaks. 

Animal Inoculations. — The general methods of animal 
inoculation have already been described. The inoculation 
of animals directly with pathological material is often of im- 
portant diagnostic value, and the special methods of doing 
so when it is necessaiy for diagnosis will be treated under 
the special headings of this section. 

Suppurative Processes. — The bacteria commonly found 
associated with these conditions are the pyogenic cocci. In 
general it may be said that the staphylococci will be found 
in the localized suppurations with abscess-formation, while 
the streptococcus will be found in the spreading inflamma- 
tions producing little pus and accompanied by lymphangitis. 

The streptococcus pyogenes may often be identified by the 
cover-glass examination alone through its characteristic 
chain-formation, but this may not be apparent and the result 
of cultures must then be awaited. 

The staphylococcus pyogenes aureus cannot usually be 
identified with any certainty by the cover-glass examination 
alone. Cultures are necessary in order to differentiate from 
the other staphylococci and from the streptococcus. 
, For practical purposes 'the identification of the pyogenic 
cocci may be made by the appearances of their colonies on 
blood-serum and by their morphology; no secondary cul- 
tures are usually necessary. 

Erysipelas. — The streptococcus is most readily found in 
the extreme margin of the affected area where the process 
is newest. The skin should be cleansed with soap and water, 
and with alcohol. Then with a sterile knife-point or a large 
needle a small wound should be made, and some of the 
blood and exudate pressed out from the tissue beneath. 
From this, cultures and cover-glasses may be prepared. 

Peritonitis and Appendicitis. — The exudate or puru- 
lent material is best obtained at the operation by means of 
swabs. A great variety of bacteria may be met with in these 
situations, the most frequent among which is the bacillus 
coli communis. 



1 82 PATHOLOGICAL TECHNIQUE. 

Pleural, pericardial, and joint exudates may con- 
tain various organisms. In purulent exudates of the pleura 
and pericardial cavities the pneumococcus is frequently pres- 
ent, as are also the pyogenic cocci. Other bacteria also 
occur here. 

The pneumococcus may be identified from the cover-glass 
examination alone by the demonstration of its capsule with 
one of the special staining methods (see p. 92), and by its 
peculiar morphology. 

In sero-purulent exudates from the joints the gonococcus 
may be present. This may be identified with some degree 
of certainty by the special staining method for the gono- 
coccus (see p. 191). 

Cultures on the special media (see p. 131) should be made 
if it is desired to remove all doubt as to the identity of the 
organism. The other pyogenic cocci also occur in purulent 
j oint-infl animations. 

If the exudate from these situations is not purulent, and 
if tuberculosis is suspected, the results of cover-glass exam- 
ination for the presence of tubercle bacilli will usually be 
negative. The main reliance in the determination of the tu- 
berculous nature of such an exudate is in the results of the 
inoculating of guinea-pigs (see p. 189). 

The animal is best inoculated with a sterile hypodermic 
syringe in the tissues of the abdominal wall, about I c.c. 
of the fluid being injected. 

Anthrax, or Malignant Pustule. — The bacilli may be 
found by the cover-glass examination of the contents of the 
small blebs and vesicles. The bacillus of anthrax may be 
identified by its morphology (see p. 156), its special charac- 
teristics being its large size and its square or concave ex- 
tremities. 

The inoculation of a mouse at the root of the tail with 
some of the material from the pustule, and the production 
of the characteristic fatal septicemia, will render the identifi- 
cation certain. 

Diphtheria. — The bacteriological diagnosis of infection 
with the bacillus diphtherias depends upon the characteristic 



BACTERIOLOGICAL EXAMINATIONS. 1 83 

morphology and peculiarities of staining, as well as rapidity 
of growth, which this organism presents when cultivated 
upon coagulated blood-serum. The identification by direct 
cover-glass examination of the exudate is very uncertain. 

The method is as follows : A blood-serum culture-tube is 
inoculated with a small amount of the material from the 
mucous membrane affected, and is placed in the incubator 
twelve to eighteen hours. After this length of time the re- 
sulting growth is examined by cover-glass preparations 
stained either with Loffler's methylene-blue solution or by 
one of the special methods given below. 

The bacillus diphtherise, if present, may then be recog- 
nized and differentiated from other bacteria present in the 
preparation by its characteristic morphology and peculiarity 
of staining, described on page 138. The gross appearances 
of the culture present little that is characteristic, as a rule, 
and the main reliance is to be placed on the microscopic ex- 
amination. Early in the infection the greater part of the 
growth may be made up of the specific bacilli, but toward 
convalescence they fall into the minority. The ordinary 
forms of agar-agar culture are not suitable for use in the 
bacteriological diagnosis of diphtheria, owing to the com- 
parative feebleness of the growth of the organism on these 
media, and because of the fact that its microscopic appear- 
ances when cultivated on such media are not sufficiently 
characteristic. 

The material for culture is very conveniently obtained by 
means of sterilized cotton swabs. In collecting this material 
the swab is removed from its test-tube and touched to the 
affected areas of the mucous membrane of either the nose or 
throat. It is then to be gently rubbed over the surface of a 
blood-serum culture-tube, or it may be replaced in the test- 
tube and the inoculation of the culture-tube made later in 
the laboratory. In the latter case the inoculation should be 
made within an hour or two after the material has been col- 
lected, the infected swab meanwhile being prevented from 
drying by firmly replacing the cotton plug. 

In cases with membrane-formation the greatest number 



184 PATHOLOGICAL TECHNIQUE. 

of bacilli are on the surface or in the upper layer of the 
membrane, and the swab should therefore be touched to 
these portions rather than to the tissue beneath. 

In addition to the coagulated blood-serum here recom- 
mended, another practical medium is the following : 

Special Culture-medium of Kanthack and Stephens. — This con- 
sists of a mixture of ascitic, pleuritic, or other similar fluid with 
agar-agar. The method of preparation is as follows : 

To every 100 c.c. of the serous fluid add 2 c.c. of a 10 per 
cent, solution of potassium hydrate, by which the serum-albumin 
of the fluid is transformed in the after-heating into alkali-albumin. 
To this add 1.5 to 2 per cent, agar-agar which has been softened 
by soaking in weakly acidulated (HO) water, and heat the mix- 
ture in the steam sterilizer until the agar-agar is dissolved. The 
mixture is then filtered through filter-paper and 4 to 5 per cent, of 
glycerin added. It is then to be run into test-tubes and sterilized 
as in the case of agar- agar (see p. 88). 

In the diagnosis of diphtheria it is used in the form of " slants " 
in the same manner as the coagulated blood-serum. 

In order to obtain this medium clear, it is necessary that the 
serous fluid should be worked into the medium as soon as possible 
after it has been withdrawn from the body. 

The advantages of this medium are — 

1. It can easily be prepared. 

2. It is clear and transparent. 

3. Its basis is a body fluid which may be readily obtained in a 
hospital. 

4. The bacillus diphtherias and certain other pathogenic bac- 
teria grow upon it rapidly and vigorously, while many common 
organisms grow upon it slowly and feebly. 

5. It can be used in the plate method of Petri. 

Note. — Before adding the potassium hydrate to the serous fluid, 
the latter should be tested in a test-tube by heating to the boiling 
temperature to determine the amount of albumin present. If a 
great amount of coagulation results, add to the serous fluid twice 
its volume of distilled water and then proceed as above indicated. 
If this dilution is not made, the mass will be gelatinous and there- 
fore useless. The serous fluid after treatment with the alkali forms 
also a good fluid culture-medium. 

Special Methods of Staining- the Bacillus Diphtherise. — 
Owing to the fact that the bacillus diphtheriae may be recognized 
by its peculiar morphology and characteristic staining in cover- 
glass preparations from its growth upon certain culture-media, as 
already pointed out, various special staining methods have been 
devised for accentuating and rendering more striking to the eye 
the peculiar deeply-stained points and granules in the bodies of 



BACTERIOLOGICAL EXAMINATIONS. 1 85 

the individual bacilli, which have been referred to as of great im- 
portance in the identification of the organism. 

These special methods of staining are said to be of great advan- 
tage in cases where only a few specific bacilli may be suspected 
to be present among a large number of other bacteria. 

Hunt' 's Method. — 1. Stain in saturated aqueous solution of 
methylene-blue one minute without heating. 

2. Wash in water. 

3. Cover with aqueous solution of tannic acid, 10 per cent., for 
ten seconds. 

4. Wash in water. 

5. Stain in saturated aqueous solution of methylene-orange one 
minute, without heating. 

6. Wash in water. 

7. Dry, and mount in balsam. 

By this method the granules, etc. are dark blue or almost black, 
and stand out very sharply against the light-green coloring of the 
body of the bacillus. The solution of methyl-orange should be 
freshly prepared, for it deteriorates in a few days. 

CroucK' 's Method. — Stain the cover-glass preparation in the fol- 
lowing mixture for a few seconds, then wash in water and mount : 

1 per cent, aqueous solution of methyl green, 5 parts; 
1 per cent, aqueous solution of dahlia, 1 part ; 

Water, 4 parts. 

By this method the deeply stained portions of the bacillus take 
on a reddish color, while the remainder of the organism is colored 
pale green. 

Method used at the Boston City Hospital. — 1. Stain with 
Lomer's methylene-blue solution, heating the preparation for a 
few seconds. 

2. Wash in a \ per cent, solution of acetic acid for a few 
seconds. 

3. Wash in water and mount. 

The partial decolorization with the acetic acid brings out the 
deeply-blue stained granules more strongly. 

Another method may be mentioned here. Whether it is of any 
use in the routine diagnosis of diphtheria we are unable to say. 
We are indebted to Dr. A. C. Abbott of Philadelphia for it. The 
method consists in staining the preparation by Gram's method 
and then staining with Bismarck-brown. The granules will be 
found to be black or blue- black and the body of the bacillus of 
a brown color. 

Influenza (see also p. 162). — Microscopic examination 
of cover-glass preparations of the bronchial sputum shows 
very small, short, round-ended bacilli, often in very large 



1 86 PATHOLOGICAL TECHNIQUE. 

numbers and frequently in the pus-cells. These bacilli fre- 
quently occur in pairs, and resemble pairs of cocci. Their 
ends may be more deeply stained than the central portions. 
For the staining of cover-glass preparations of the sputum 
PfeifTer recommends that a very dilute carbol-fuchsin solution 
be applied for five to ten minutes. The cover-glass prepara- 
tion is to be made from a distinctly purulent portion of the 
sputum. Staining with LofBer's methylene-blue solution 
also gives good results. 

The bacillus of influenza may be cultivated from the sputum 
by breaking up a small portion of a distinctly purulent cha- 
racter in i or 2 c.c. of bouillon, and then spreading a 
platinum loopful of the suspension over the surface of a 
blood-agar-agar slant, which is then placed in the incubator. 
After eighteen to twenty-four hours the characteristic col- 
onies may be visible with the aid of a hand-lens. These 
should not grow in ordinary media unless blood or hemo- 
globin be present, and should have the morphology of the 
bacillus of influenza. 

Examination of Sputum for Tubercle Bacilli. — 
The morning sputum should be taken for examination. Se- 
lect one of the dense, grayish-white particles, and with the 
aid of small pointed forceps or the platinum wire rub it over 
the surface of a cover-glass, breaking it up as much as pos- 
sible. The material should be spread in a very thin layer. 
The preparation is next to be " fixed " in the ordinary way 
described for cover-glass preparations (see p. 89), and is 
then to be treated as follows : 

1. Stain in carbol-fuchsin solution, steaming for one 
minute over the Bunsen flame, with the staining solution 
thoroughly covering all the surface of the cover-glass. 
None of the surface of the cover-glass should be allowed 
to become dry by evaporation, as this causes a precipitate 
to form, but more of the staining fluid should be added 
from time to time to keep it completely covered as evapora- 
tion occurs. 

2. Wash in water. 

3. Cover with Gabbet's solution for twenty seconds. The 



BACTERIOLOGICAL EXAMINATIONS. 1 87 

solution should also be applied to the uncharged slide of the 
cover-glass to remove any dried stain which may have col- 
lected thereon. 

4. Wash thoroughly in water. 

5. Mount in water or balsam. Water is to be preferred, 
for the reason that the apparent size of the bacilli is larger 
when examined in water. 



/ / 



S- 



Fig. 74. — Tubercle bacilli in sputum (carbol-fuchsin and methylene-blue). 

Another method is as follows : 

1. Stain in carbol-fuchsin solution or aniline-fuchsin solu- 
tion in the manner above indicated. 

2. Wash in water. 

3. Wash in 95 per cent, alcohol for a few seconds. 

4. Decolorize in a solution composed of — 

Water, 150 c.c. ; 

Alcohol, 50 " 

Concentrated sulphuric acid, 30 drops, 

until the preparation has a faint pink color. 



1 88 PATHOLOGICAL TECHNIQUE. 

5. Wash thoroughly in water. 

6. Stain for thirty seconds with Loffler's methylene-blue 
solution without heating. 

7. Wash in water and mount. 

By both of these methods the tubercle bacilli are stained 
red, while other bacteria and the nuclei of cells are stained 
blue (Fig. 74). There are other methods for staining tuber- 
cle bacilli, but these fulfil all the requirements of practical 
work. 

Tubercle bacilli, when present in sputum in very small numbers, 
may sometimes be demonstrated by methods of sedimentation. A 
good means of sedimentation consists in heating the sputum in a 
test-tube either with boiling water or in the steam sterilizer for 
fifteen minutes. The heat coagulates the cells and albuminous 
constituents, which sink to the bottom, carrying with them the 
bacilli. The supernatant liquid may then be poured off and the 
sediment examined as above. 

Another method of treating the sputum when only a small 
number of bacilli may be present is as follows : Place 10-15 c - c - 
of the sputum in a wide-mouthed bottle of 100 c.c. capacity. 
Add 10 c.c. of water and 6 c.c. of liquefied carbolic-acid crystals. 
Close the flask with a rubber cork and shake for one minute. 
After shaking, fill the bottle with water and shake again. Then 
pour the contents of the bottle into a sedimenting glass, let stand 
for twelve to twenty-four hours, and examine the sediment. The 
cover-glass preparations of the sediment before staining are to be 
washed in ether or chloroform, and then in alcohol, or they may 
be washed in a mixture of alcohol and ether, equal parts. 

Tubercle Bacilli in Urine. — The sediment of the urine 
should be examined. This may be rapidly thrown down by 
the centrifuge. 

In urine smegma bacilli may be mistaken for tubercle 
bacilli, especially in the urine of females. The smegma 
bacillus resembles the tubercle bacillus very closely in form, 
and, like the latter, it retains its stain in the presence of acids. 
It differs from the tubercle bacillus, however, in that it is de- 
colorized by alcohol. Therefore in staining for tubercle 
bacilli in the urine alcohol should be used in decolorizing. 
The procedure is as follows : 

I. Make a cover-glass preparation from the sediment. 



BACTERIOLOGICAL EXAMINATIONS. 1 89 

2. Stain with carbol-fuchsin solution for one minute, as 
described in the case of sputum. 

3. Wash in water. 

4. Decolorize in 20 per cent, sulphuric acid until the prep- 
aration has a pink color. 

5. Wash thoroughly in water. 

6. Wash in alcohol (95 per cent.) thirty seconds. 

7. Wash in water. 

8. Stain with Loffler's methylene-blue solution twenty 
seconds, without heat. 

9. Wash in water and mount. 

Surgical Tuberculosis. — The demonstration of the tu- 
berculous nature of material removed at operations may be 
made by the histological examination, by the demonstration 
of the tubercle bacilli on cover-glass preparations, as in 
sputum, and by the results of the inoculation of guinea-pigs 
with the material. Cultures are not ordinarily practicable. 

The examination of cover-glass preparations is commonly 
of little value, owing to the small number of bacilli usually 
present. 

The histological examination may be often made very sat- 
isfactorily by frozen sections of the tissues. If possible, how- 
ever, regularly hardened and imbedded tissues, cut in fairly 
thin sections and stained with hematoxylin and eosin, are 
preferable. 

The inoculation of guinea-pigs is to be made subcutane- 
ously in the abdominal wall, either with a hypodermic syr- 
inge if the material is fluid, or, if it be in the form of tissue, by 
inserting a small piece beneath the skin. Material obtained 
on a swab may also be used for inoculation by introducing 
the infected swab beneath the skin and moving it back and 
forth a few times. If tubercle bacilli are present in the ma- 
terial, the animal will show enlargement of the inguinal 
lymphatic glands in about three weeks and will usually die 
of miliary tuberculosis in the course of six to ten weeks. If 
necessary, the glands in the inguinal region may be examined 
histologically after three weeks for the presence of tubercu- 
lar lesions, or examined by cover-glass preparations for tu- 



I90 PATHOLOGICAL TECHNIQUE. 

bercle bacilli. The discharges from sinuses, etc. may also 
be tested for the presence of tubercle bacilli as above indi- 
cated, the material being obtained on a " swab." 

Cultures from the Blood during I,ife. — With a steril- 
ized hypodermic syringe secure a cubic centimeter of blood 
from one of the large veins at the flexure of the elbow. Mix 
this immediately with one or two tubes of fluid agar-agar 
which has been kept at hand at a temperature of about 40 C. 
and form a "slant," or make a Petri plate of the mixture. 
(For keeping the agar-agar tubes at the desired temperature 
an ordinary cup or similar vessel filled with water of the 
proper temperature will suffice.) 

When the " slant " or " plate " has become solid it is to be 
placed in the incubator for development. 

It may be mentioned that this mixture of blood and agar- 
agar is a good medium for the growth of the gonococcus, 
and that this organism has been cultivated from the blood in 
gonorrheal endocarditis by this means. Before puncturing 
the vein the skin over it should be thoroughly cleansed with 
alcohol and ether, but no antiseptics, such as carbolic acid 
or corrosive sublimate, should be used. The syringe should 
be thoroughly sterilized by steam for half an hour, and 
should be brought to the patient in a sterilized test-tube, 
from which it should be removed only when it is to be used. 

Intraperitoneal inoculation of mice may also be made with 
j to 1 c.c. of the blood. This may give rise to strepto- 
coccus or pneumococcus septicemia. 

Gonorrhea. — Cover-glass examination of the pus shows 
cocci in the form of paired hemispheres, mainly inside pus- 
cells (Fig. 75). For the identification of these cocci as gono- 
cocci their morphology and position inside the leucocytes are 
not alone sufficient, for essentially the same appearances may 
be sometimes seen in pus infected with staphylococci or 
streptococci. 

A positive diagnosis of infection with the gonococcus is 
not justified until it has been determined that the cocci are 
decolorized by Gram's method, for the ordinary pyogenic 
cocci are stained by this method. 



BACTERIOLOGICAL EXAMINATIONS. 191 

Prepare a cover-glass with the pus, spreading it thinly 
with the platinum wire. The practice of spreading a small 
drop of pus between two cover-glasses and drawing them 
apart is objectionable. After " fixing " (see p. 89) stain the 
preparation by the following method: 



<& ; 



-■* -■ 






&».\ 







■& 



m 

FIG. 75. — Gonococci in leucocytes : cover-glass preparation of gonorrheal pus. 



IP W. ** 



Method of Staining" for Gonococci. — 1. Stain with aniline- 
gentian-violet solution for thirty seconds, without heating. 

2. Wash in water. 

3. Cover the preparation with Gram's iodin solution for 
thirty seconds. 

4. Wash in water. 

5. Wash with alcohol (95 per cent.) until the color ceases 
to come out of the preparation. 

6. Wash in water. 

7. Stain in saturated aqueous solution of Bismarck brown 
for thirty seconds. 

8. Wash in water and mount. 

This method is nothing but Gram's method and after- 
staining with Bismarck brown. With it the gonococci are 
stained brown, and other pyogenic cocci stained blue-black. 

If it is desired to obtain cultures of the gonococcus from 
the pus of gonorrheal urethritis, the case should not be more 
than of a few days' duration, because cases of longer dura- 



I92 PATHOLOGICAL TECHNIQUE. 

tion will usually show the presence of other bacteria whose 
colonies overgrow the feebly growing colonies of the gono- 
coccus. An organism which may be mistaken for the gono- 
coccus is a coccus growing in large milk-white colonies on 
all media, but staining by Gram's method. This coccus is 
frequently found in gonorrheal pus after the discharge has 
lasted several days. Other cocci also occur. 

The pus for culture purposes may be collected on a 
"swab," and the special culture-medium (see page 131) di- 
rectly infected with this. The gonococcus retains its vitality 
in the pus on the. swab for a number of hours, but care 
should be taken to avoid drying. 

Gonorrheal Conjunctivitis. — Prepare cover-glass prep- 
arations of the pus and stain by the special method for 
gonococci given above. If gonococci are present, they must 
be stained brown — i. e. they must be shown to be decolor- 
ized by Gram's method before the diagnosis of gonorrheal 
infection is justified. 

If it is desired to obtain cultures of gonococci from this 
condition, the special medium must be used as above men- 
tioned. 

Pyosalpinx. — In a certain proportion of cases of puru- 
lent inflammation of the Fallopian tubes gonococci may be 
found and cultivated, as above indicated. The majority of 
cases, however, will have sterile pus, while in a small per- 
centage of cases the ordinary pyogenic cocci will be present. 

Cerebro-spinal Meningitis (see also the section on 
Lumbar Puncture). — It is claimed that the nasal secretion in 
the epidemic form of this disease contains the diplococcus 
intracellularis meningitidis (see Bacteriological Diagnosis). 
There is no doubt that diplococci, decolorizing by Gram's 
method and often situated in polynuclear leucocytes, are to 
be found in the nasal secretion of certain cases of this dis- 
ease, but whether their presence is pathognomonic of cere- 
bro-spinal meningitis is not yet determined. 

The material for examination is best obtained with the 
platinum loop from the superior portions of the nasal cav- 
ities. From it cover-glass preparations are made and stained 



BACTERIOLOGICAL EXAMINATIONS. 1 93 

by the method described above for gonococci. The diplo- 
cocci, if present, will be stained brown. 

The microscopical appearances presented by the prepara- 
tion may be very like those of preparations of gonorrheal 
pus. Cultures on blood-serum may be also made from the 
nasal secretion, but the growth of the diplococci on them is 
uncertain. 

Glanders. — In a case of suspected glanders the dis- 
charges from sinuses or ulcerated surfaces, or the contents 
of pustules, are to be examined for the presence of the 
bacillus of glanders by the usual methods. 

The material for examination may be collected on " swabs." 
With this a guinea-pig is to be inoculated and cultures and 
cover-glass preparations are made. If the material be from 
sinuses or ulcerated surfaces, the isolation of the bacillus by 
cultures will be difficult, owing to the presence of other or- 
ganisms. The guinea-pig is to be inoculated in the perito- 
neal cavity by introducing the infected swab into it through 
an incision in the abdominal wall, or by injecting about 1 
c.c. of a suspension in bouillon of the suspected material 
into the peritoneal cavity with a hypodermic syringe. 

If the bacillus of glanders is present, the scrotum will 
usually show the characteristic swelling and inflammation in 
the course of three or four days, and death will occur after 
some weeks. In some cases the animal may die in thirty- 
six or forty-eight hours. In any case the characteristic 
lesions of glanders will be found as described elsewhere, 
and the bacillus may be isolated from them by cultures. 
The spleen will practically always yield glanders bacilli in 
pure culture even if no macroscopic lesion can be made out, 

In cultures the organism should show those characteristics 
of morphology, of culture, and of pathogenesis which have 
been described in the section on Bacteriological Diagnosis. 

Tetanus. — The isolation of the tetanus bacillus is a very 
difficult task, and attempts to cultivate it from cases of 
tetanus are often without success. 

Method of Isolation. — Inoculate several mice subcutane- 
ously with the secretion of the wound. If tetanus results 

13 



194 PATHOLOGICAL TECHNIQUE. 

in the mice, there will usually be some suppuration about 
the point of inoculation owing to the presence of other* 
organisms. Smear some of this inflammatory exudation 
from the point of inoculation on the surface of several 
blood-serum tubes, and place in the incubator. After twenty- 
four hours the microscopical examination of the growth 
may reveal the presence of a few of the characteristic 
drumstick-shaped, spore-bearing bacilli (p. 170). If these 
are present, the culture is then replaced in the incubator 
for twenty-four hours, and then heated in a water-bath at 
8o° C. for about three-quarters of an hour. Then make 
from the growth several anaerobic cultures by any of the 
methods (see section on Methods of Cultivation without 
Oxygen). 

In the anaerobic cultures the colonies which develop 
should not only be composed of the bacilli of the charac- 
teristic morphology, but they should show the characteristic 
pathogenesis for mice (see section on Bacteriological Diag- 
nosis). If gelatin is used as a culture-medium, the colonies 
appear after about a week. 

Langdon Frothingham 1 has used the following method 
with success in the isolation and identification of the bacil- 
lus from cases of tetanus in horses : 

1. Inoculate alkaline bouillon with the pus from the 
wound, or, pus being absent, with small bits of tissue from 
the inside of the wound, or, in the case of experiment ani- 
mals inoculated with pure cultures, with bits of tissue from 
the region of the point of inoculation. 

2. Place the tubes in an atmosphere of hydrogen and in 
the incubator for forty-eight hours. 

3. Examine microscopically, and if tetanus bacilli are 
present — 

4. Heat from three-quarters of an hour to an hour in 
water-bath kept at a temperature of 8o° C. 

5. From the heated tubes inoculate fresh bouillon cultures 
(under hydrogen) and place in the incubator for forty-eight 
hours. 

1 Am. Jonm. Med. Sci., May, 1894. 



BACTERIOLOGICAL EXAMINATIONS. 1 95 

6. Test the purity by microscopic examination and by 
cultures in glucose-gelatin, glucose-agar, etc. 

7. Test the virulence on mice, white or gray. 

Asiatic Cholera. — Bacteriological Diagnosis} — Because of 
the manifold channels which are open for the dissemination of 
this disease it is of the utmost importance that its true nature 
should be recognized as quickly as possible, for with every 
moment of delay in its recognition opportunities for its spread 
are multiplying. It is essential, therefore, when employing bac- 
teriological means in making the diagnosis to bear in mind those 
biological and morphological features of the organism that appear 
most quickly under artificial methods of cultivation, and which 
at the same time may be considered as characteristic of it — viz. 
its peculiar morphology and grouping ; the much greater rapidity 
of its growth over that of other bacteria with which it may be 
associated ; the characteristic appearance of its colonies on gela- 
tin plates and of its growth in stab-cultures in gelatin ; its property 
of producing indol and coincidently nitrites in from six to eight 
hours in pepton solution at 37 to 38 C. ; and its power of causing 
the death of guinea-pigs in from sixteen to twenty- four hours when 
introduced into the peritoneal cavity, death being preceded by 
symptoms of extreme toxemia, characterized by prostration and 
gradual and continuous falling in temperature of the animal's body. 

In a publication recently made by Koch 2 he called attention to 
a plan of procedure that is employed in this work in the Institute 
for Infectious Diseases in Berlin. In this scheme the points that 
have been enumerated are taken into account, and by its employ- 
ment the diagnosis can be established in the majority of cases of 
Asiatic cholera in from eighteen to twenty-two hours. In general, 
the steps to be taken and the points to be borne in mind are as 
follows. The material should be examined as early as possible 
after it has been passed : 

1. Microscopic examination. From one of the small slimy 
particles that will be seen in the semifluid evacuation prepare a 
cover-slip preparation in the ordinary way and stain it. If, upon 
microscopic examination, only curved rods or curved rods greatly 
in excess of all other forms are present, the diagnosis of Asiatic 
cholera is more than likely correct ; and particularly is this true 
if these organisms are arranged in irregular linear groups, with the 
long axis of all the rods pointing in nearly the same direction ; 
that is to say, somewhat as minnows arrange themselves when 
swimming in schools up stream (Koch). 

In 1886, Weisser and Frank 3 expressed their opinion upon the 
value of microscopic examination in these cases in the following 
terms : 

1 Abbott : Principles of Bacteriology. 

2 Zeitschrift f. Hygiene u. Infectionskrankheiten, Bd. 14, 1893. 

3 Ibid., Bd. I, p. 397. 



I96 PATHOLOGICAL TECHNIQUE. 

(a) In the majority of cases microscopic examination is suf- 
ficient for the detection of the presence of the comma bacillus in 
the intestinal evacuations of cholera patients. 

(J?) Even in the most acute cases, running a very rapid course, 
the comma bacillus can always be found in the evacuations. 

(V) In general the number of cholera spirilla present is greater 
the earlier death occurs ; when death is postponed and the disease 
continues for a longer period, their number is diminished. 

(</) Should the patient not die of cholera, but from some other 
disease, such as typhoid fever, that may be engrafted upon it, the 
comma bacilli may disappear entirely from the intestines. 

2. With another slimy flake prepare a set of gelatin plates. 
Place them at a temperature of from 20 to 22 C, and at six- 
teen, twenty-two, and thirty-six hours observe the appearance of 
the colonies. Usually at about twenty-two hours the colonies of 
this organism can easily be identified by one familiar with them. 

3. With another slimy flake start a culture in a tube of pepton 
solution — either the solution of Dunham or, as Koch proposes, a 
solution of double strength of that of Dunham (Witte's pepton is 
to be used, as it gives the best and most constant results). Place 
this at 37 to 38 C, and at the end of from six to eight hours 
prepare cover-slips from the upper layers (without shaking) and 
examine them microscopically. If comma bacilli are present and 
capable of multiplication, they will be found in this locality in 
almost pure culture. After doing this prepare a second pepton 
culture from the upper layer, also a set of gelatin plates, and with 
what remains make the test for indol by the addition of 10 drops 
of concentrated sulphuric acid for each 10 c.cm. of fluid con- 
tained in the tube. If comma bacilli are growing in the tube, 
the rose color characteristic of the presence of indol should 
appear. 

By following this plan "a bacteriologist who is familiar with 
the morphological and biological peculiarities of this organism 
should make a more than probable diagnosis at once by micro- 
scopic examination alone, and a positive diagnosis in from twenty 
to, at the most, twenty-four hours after beginning the examination' ' 
(Koch). 

There are certain doubtful cases in which the organisms are 
present in the intestinal canal in very small numbers, and micro- 
scopic examination is not, therefore, of so much assistance. In 
these cases plates of agar-agar, of gelatin, and cultures in the pep- 
ton solution should be made. 

The plates of agar-agar should not be prepared in the usual 
way, but the agar-agar should be poured into Petri dishes and al- 
lowed to solidify, after which one of the slimy particles may be 
smeared over its surface. The comma bacillus being markedly 
aerobic, develops very much more readily when its colonies are 
located upon the surface than when they are in the depths of the 
medium. A point to which Koch calls attention in connection 



BACTERIOLOGICAL EXAMINATIONS. 1 97 

with this step in the manipulation is the necessity for having the 
surface of the agar-agar free from the water that is squeezed from 
it when it solidifies, as the presence of the water interferes with 
the development of the colonies as isolated points and causes 
them to become confluent. To obviate this, he recommends that 
the agar-agar be poured into the plates and the water allowed 
to separate from the surface at the temperature of the incubator 
before they are used. It is wise, therefore, when one is liable 
to be called on for such work as this to keep a number of 
sterilized plates of agar-agar in the incubator ready for use, just 
as sterilized tubes of media are always ready and at hand. The 
advantage of using the agar plates is the higher temperature 
at which they can be kept, and consequently a more favorable 
condition for the development of the colonies. As soon as iso- 
lated colonies appear they should be examined microscopically for 
the presence of organisms having the morphology of the one for 
which we are seeking, and as soon as such is detected gelatin plates 
and cultures in pepton solution (for the indol reaction) should be 
made. The pepton cultures started from the original material 
should be examined microscopically from hour to hour after the 
sixth hour that they have been in the incubator. The material 
taken for examination should always come from near the surface 
of the fluid, and care should be taken not to shake the tube. As 
soon as comma bacilli are detected in anything like considerable 
numbers in the upper layers of the fluid, agar-agar plates and 
fresh pepton cultures should be made from them. The colo- 
nies will develop on the agar-agar plates at 37 C. in from ten 
to twelve hours to a size sufficient for recognition by microscopic 
examination, and from this examination an opinion can usually 
be given. This opinion should always be controlled by cultures 
in the pepton solution made from each of several single colonies, 
and finally the test for the presence or absence of indol in these 
cultures. 

In all doubtful cases in which only a few curved bacilli are pres- 
ent or in which irregularities in either the rate or mode of their 
development occurs, pure cultures should be obtained by the 
agar-plate method and the method of cultivation in pepton solu- 
tion as soon as possible, and their virulence tested upon animals. 
For this purpose cultures upon agar-agar from single colonies 
must be made. From the surface of one of such cultures a good- 
sized wire-loopful should be scraped, and this broken up in about 
1 c.c. of bouillon, and the suspension thus made injected by 
means of a hypodermic syringe directly into the peritoneal cavity of 
a guinea-pig of about 350 to 400 grams weight. For larger*animals 
more material should be used. If the material injected is from a 
fresh culture of the cholera organism, toxic symptoms at once 
begin to appear ; these have their most pronounced expression in 
the lowering of temperature, and if one follows this decline in 
temperature from time to time with the thermometer, it will be 



I98 PATHOLOGICAL TECHNIQUE. 

seen to be gradual and continuous from the time of injection to 
the death of the animal, which occurs in from eighteen to twenty- 
four hours after the operation. 1 

In general, this is the procedure employed at Berlin in the In- 
stitute for Infectious Disease under Koch's direction. 

Typhoid Fever. — The bacteriological diagnosis of this 
disease may be made by two methods. One of these con- 
sists in the isolation of the typhoid bacillus from the feces by 
means of special culture-media ; the other depends upon a 
peculiar effect which the blood-serum of a typhoid patient 
exerts upon a suspension of typhoid bacilli when a mixture 
of the two is made. 

Isolation of the Typhoid Bacillus from the Feces. — 
This may be accomplished in a certain proportion of cases 
by making Petri plate cultures from the feces with either of 
the following special culture-media. The material for cul- 
tures may be very conveniently secured by means of a 
" swab," and brought to the laboratory in the sterile test- 
tube. A few grams of fecal material should be obtained, 
as this quantity will not readily dry up. 

We are indebted to Dr. Mark W. Richardson of Boston 
for the following directions for preparing the special culture- 
medium of Eisner, and for the description of the method of 
applying it to the isolation of the typhoid bacillus from the 
stools, as practised by him : 

1. Pare carefully and cut up into small pieces \ kilogram 
of potatoes. The potatoes should be old rather than new, 
and not too large. The best size it that of an egg or slightly 
larger. New or large potatoes are too acid in reaction, 
hence are not to be used. 

2. Add 1 liter of water and boil for one and a half hours. 

3. Mash potatoes thoroughly. 

4. Measure and make up to 1 liter the loss of water by 
evaporation. 

5. Strain through a cloth. 

6. Make up amount once more to 1 liter. 

7. Boil with 1 5 per cent, gelatin for five or ten minutes. 

1 Pfeiffer : loc. cit. 



BACTERIOLOGICAL EXAMINATIONS. 1 99 

8. Cool down to 6o° C, and add a well-beaten egg to 
clear. Boil. 

9. Filter through cotton. 

10. Filter through paper. 

11. Test acidity with decinormal (4 grams to 1000 c.c.) 
sodium hydrate solution. The acidity should be such, ac- 
cording to Eisner, that 10 c.c. of gelatin are neutralized by 
2.5 to 3 c.c. of the solution of alkali. The acidity may be 
somewhat lower, however (1.7 c.c), with no harmful results. 
An acidity above 3 is to be corrected with normal sodium 
hydrate solution (40 grams to 1000 c.c). 

12. Add potassium iodid 1 per cent. This may be added — 

(a) Before tubing the medium, in which case add to 1 liter 
of media 10 c.c. of a solution in which 1 c.c. is equivalent to 
1 gram of potassium iodid, and mix thoroughly ; or, 

(b) Just before using the medium, in which case we add to 
10 c.c. of medium -^ c.c of the above solution. 

13. Tube, and sterilize three times. 

In the examination of a suspected typhoid stool the first 
dilution is made with one " loop " of stool into bouillon (to 
economize on the medium) or into the medium itself. 

Three or four Petri plates are generally sufficient, the dilu- 
tions being made as follows : 

Plate II. = 1 loop from plate I. or from the bouillon tube. 

Plate III. = 1 loop from plate II. 

Plate IV. =6 loops from plate III. 

The plates are now kept at room-temperature (as near 
20°-22° C. as possible) for forty-eight hours. The colonies 
of the bacillus coli communis appear in twenty-four hours, 
but it is rare to see the typhoid colonies before the end of 
forty-eight hours. Naked-eye appearances have little or no 
value. The plates are best examined under the microscope 
with a Zeiss AA or Leitz No. 3 lens. Seen under these cir- 
cumstances, at the end of forty-eight hours the colon col- 
onies appear as larger, rounder, more well defined, coarsely 
granular, distinctly brown-colored colonies, while the typhoid 
colonies are much smaller, paler, less sharply defined, very 
finely granular, and are more often oval than round in shape. 



200 PATHOLOGICAL TECHNIQUE. 

It is, however, very important that the plates should not 
be too crowded, otherwise the small colonies of the bacillus 
coli communis may give rise to considerable confusion. The 
suspicious colonies are now picked up (always under the 
microscope) and transferred to bouillon and glucose agar- 
agar tubes. 

If, after twenty-four hours in the incubator, there has 
been no formation of gas on the glucose agar-agar, and the 
bouillon culture shows, in the hanging drop, an organism 
resembling in morphology and motility the typhoid bacillus, 
then the other tests for the typhoid bacillus (see Bacterio- 
logical Diagnosis) are indicated ; for the appearances alone 
of the colony upon the potato-gelatin is certainly no more 
proof of the identity of the bacillus than any other one 
of the differential tests, unless it be the serum-reaction of 
Pfeiffer. 

Capaldi's Culture-medium. 

Distilled water, ioooc.c. ; 

Pepton (Witte), 20 grams ; 

Gelatin, 10 " 

Glucose, 10 " 

Sodium chlorid, 5 " 

Potassium chlorid, 5 " 

Make a solution of this composition and filter. To the fil- 
trate add 20 grams of agar-agar and 10 c.cm. of a normal 
solution of sodium hydrate (40 grams to 1000 c.c). 

With this medium Petri plate-cultures are to be made 
from the stools by first pouring the medium into the plates, 
allowing it to become solid, and then inoculating .the sur- 
face by gently rubbing the infected platinum loop over it. 
The loop may be infected either by plunging it into the stool 
or into a bouillon suspension of the stool. In consequence 
of this manner of inoculating the plates the colonies all grow 
on the surface, and thus show more clearly anything charac- 
teristic in their appearance than if they developed in the 
depths of the medium. The colonies of the typhoid bacil- 
lus, when grown upon this medium, are shining, transparent, 



BACTERIOLOGICAL EXAMINATIONS. 201 

almost colorless, and smaller than the opaque grayish-white 
colonies of the bacillus coli communis. 

Of course suspected colonies must be shown to be com- 
posed of bacilli which conform to the various tests described 
elsewhere before they can be identified with any degree of 
certainty as those of the typhoid bacillus. 

The Blood-serum Reaction in Typhoid Fever. — A few 
drops of the blood of a suspected case of typhoid fever are 
collected in a small test-tube, either from the finger or the 
ear. After clotting has taken place, transfer a drop of the 
serum by means of a medicine-dropper to 0.5 or 1.0 c.c. 
of a twenty-four-hour bouillon culture of the typhoid bacillus. 
After mixing, place a drop of the mixture on a slide, cover 
it with a cover-glass, and examine it with either an oil-im- 
mersion lens or a high-power dry lens. If desired, the mix- 
ture may also be examined as a hanging-drop preparation. 

If the patient has typhoid fever, the majority of the bacilli 
on the preparation will be seen to lose their motility and to 
" agglomerate " into clumps within a very few minutes. 
This constitutes the serum-reaction. It is only demonstrable, 
as a rule, after the first week of the disease. 

The reaction may also be obtained from the dried blood. 
A few drops of the blood may be collected on a glass slide 
or a piece of paper and allowed to dry. It may then be 
brought to the laboratory, where the dried blood is extracted 
with 15 or 20 drops of water, and the test made with a drop 
of the solution thus obtained, by mixing it with a drop of 
an eighteen- to twenty-four-hour bouillon culture of the 
typhoid bacillus, and observing the mixture with the high- 
power dry lens after covering with a cover-glass. 

Rabies (Hydrophobia). — The diagnosis of this disease 
from a pathological standpoint is usually made by the pro- 
duction of experimental rabies in a rabbit by intradural in- 
oculation with material from the nervous system of the ani- 
mal suspected to have died of it. The poison of the dis- 
ease is found in the brain, spinal cord, salivary glands, and 
pancreas. For purposes of inoculation a piece (1 or 2 c.c.) 
of the medulla or brain, preferably the former, is rubbed up 



202 



PA THOL GICAL TECHNIQ UE. 



in a sterilized mortar with about 10 c.c. of sterilized dis- 
tilled water. The resulting fluid is filtered through absorb- 
ent cotton, and then through filter-paper, to remove tissue- 
shreds. Of the clear fluid thus obtained 4 or 5 drops are 
injected beneath the dura of a rabbit by means of a hypo- 
dermic syringe, the skull being trephined with a small trephine 
about 4 mm. in diameter. The most favorable place for 
opening the skull is at a point in the median line just pos- 
terior to a line drawn through the middle of each eye. 

The symptoms of experimental rabies in the rabbit first 




FIG. 76. — Bacillus of leprosy : section through a subcutaneous node, showing the 
bacilli in tissue-cells; X 500 (Frankel and Pfeiffer). 

manifest themselves after two weeks, never earlier, but they 
may not appear until later, not even until two months have 
passed. The first symptom is a weakness of the hind legs, 
followed by paralysis. The paretic condition soon extends 
to the fore legs, dyspnea appears, and death usually occurs in 
about three days after the onset of the symptoms. Paralytic 
symptoms developing before two weeks are not due to infec- 
tion with rabies, but to some other cause ; for instance, in- 



BACTERIOLOGICAL EXAMINATIONS. 203 

fection with the pneumococcus or other bacteria which may 
be present in the material inoculated. 

During the course of the disease the animal never appears 
stupid, with dull eyes, as in other infections, but remains 
" conscious," so to speak, until the last. 

I^eprosy. — The bacillus of this disease shows essentially 
the same staining reactions as the bacillus tuberculosis. In 
sections of the lesions the bacilli are found in large numbers, 
mostly inside the tissue-cells (see Fig. 76). 

Actinomycosis. — The microscopical diagnosis has been 
discussed in the section on Bacteriological Diagnosis. 



PART III. 
HISTOLOGICAL METHODS. 



Introduction. — The ideal function of the technique of 
pathological histology is so to fix tissues for microscopic 
examination that every tissue-element or pathological prod- 
uct is perfectly preserved with all its morphological and 
chemical properties intact, and so to stain tissues that every 
tissue-element or pathological product can be readily differ- 
entiated from any other tissue-element or pathological prod- 
uct that resembles it. In certain respects only has this ideal 
yet been reached, but the number of differential stains is 
increasing yearly. 

In the following pages the various steps in the prepara- 
tion and staining of tissues have been arranged, so far as 
possible, in logical sequence. 

LABORATORY OUTFIT. 

Microscopes. — The most important laboratory instru- 
ment is the microscope. It should be, so far as means will 
permit, the best that skill can produce. The two foreign 
makes of microscopes most in favor in this country are the 
Zeiss and the Leitz. Excellent microscopes are also made 
by Reichart, Hartnack, and Seibert. American microscopes 
have greatly improved during the past few years, but do not 
yet reach the standard set by the best foreign makes. Un- 
doubtedly the best microscopes in every particular and the 
most expensive are those manufactured by Zeiss. 

It is important for a beginner in microscopy, before buy- 
ing a microscope of any make, to have it carefully examined 
and its lenses tested at a pathological or other laboratory by 

204 



HISTOLOGICAL METHODS. 20 5 

some one skilled in its use. The continental form of stand 
of medium size is to be preferred to all others. The large 
stand is undesirable, because it is too heavy and too high for 
comfortable use. It should be furnished with rack and pin- 
ion, and with micrometer screw for coarse and fine adjust- 
ment, with a triple nose-piece, and with an Abbe condenser 
and iris diaphragm. The necessary objectives are a low and 
a high dry, and a yy oil-immersion. Two eye-pieces, a low 
and a high, will be found sufficient for all ordinary purposes. 

The stands, oculars, and objectives generally used are the 
following : 

Zeiss: Stands, 11a, TV a, TVb. 

Oculars, 2 and 4. 

Objectives, AA, D, and -^ oil-immersion. 

Leitz : Stands, la, lb, II, lie. 

Oculars, 1 and 3. 

Objectives, 3, 7, and y 1 -^ oil-immersion. 

Even if all these different parts cannot be purchased at 
the same time, it is important to buy a stand to which they 
afterward may be added, for the list includes only what every 
medical practitioner should have at his service for the proper 
examination of urine, sputum, blood, etc. 

The apochromatic lenses and compensation oculars are 
too expensive to come into general use. Fortunately, they 
are more important for photomicrography than for general 
microscopic work. 

The oil-immersion lens should always be cleaned after 
using by wiping off the oil with an old linen or silk hand- 
kerchief or with the fine tissue-paper now manufactured for 
that purpose. If the lens is sticky, moisten the cloth with 
benzol or xylol ; Leitz recommends alcohol. The same 
process can be used if necessary for the dry lenses, but it 
must be done quickly, so as not to soften the balsam in 
which the lenses are imbedded. Ordinarily a dry cloth is 
sufficient. 

In using the Abbe illuminating apparatus it is important 
to bear in mind that the best results are obtained, according 
to Zeiss, by employing the plain mirror, for the condenser is 



206 PATHOLOGICAL TECHNIQUE. 

designed for parallel rays of light. The concave mirror is 
to be used only when some near object, such as the window- 
frame, is reflected into the field of vision or when artificial 
light is employed. 

A mechanical stage is now made which can be instantly 
attached to any microscope. It is exceedingly useful for 
blood-counting or for searching carefully the whole surface 
of a stained cover-slip. For ordinary work it is undesirable. 

For microscopic work the best illumination is that obtained 
from a white cloud. When artificial light is necessary, the 
Welsbach burner, or, better still, the Edison electric lamp with 
ground-glass globe, will be found very satisfactory. The 
slight yellowish tint of the light can be corrected, if neces- 
sary, by means of a piece of blue glass inserted over the 
mirror or just below the object to be examined. 

For drawing, the Abbe camera lucida will be found ex- 
tremely useful and convenient. Leitz has recently con- 
structed two new drawing oculars, of which the one to be 
used with the microscope inclined at an angle of 45 ° would 
seem to be very practicable. With the other the drawing 
surface has to be inclined at an angle of 12 to avoid dis- 
tortion of the image. 

Freezing Microtome. — Freezing by means of the 
evaporation of ether, more rarely of rhigolene, is the method 
in general use. The process is both expensive and slow. 
A much cheaper and more rapid method of freezing was 
originated several years ago in the Sears Pathological Labo- 
ratory by Dr. S. J. Mixter, and has since been in constant 
use both here and in the hospitals in Boston. This method 
consists in the employment of compressed carbon-dioxid, 
which is found in commerce in iron cylinders containing 
each about twenty pounds of liquefied gas. It is commonly 
used for charging beer and soda-water. As a rule, the 
cylinders are loaned, so that it is necessary to pay for the 
contents only. 

The cylinder must be securely fastened in an upright posi- 
tion near the microtome, with its valve end below and with 
its escape-tube on a level with the entrance-tube into the 



HISTOLOGICAL METHODS. 207 

freezing-box. The cap covering the escape-tube of the 
cylinder should have a small hole bored through it, and into 
this hole a small brass tube about 5 cm. long, with a fine 
bore, should be tightly driven. This permits the use of a 
smaller stream of gas than the escape-pipe of the cylinder 




FIG. 77. — Freezing microtome. 

would otherwise furnish. The same cap can be kept to use 
on all future cylinders. 

The cylinder is connected with the microtome by means 
of a short piece of thick, strong rubber tubing with small 
bore, so as to fit snugly over the escape-tube of the cylinder 
and the entrance-tube into the freezing-box. Sometimes it 
is advisable to tie with string each end of the rubber tubing 
around the tube it encloses. The rubber tubing acts as a 



208 PATHOLOGICAL TECHNIQUE. 

safety-valve in case the pressure of gas should by any acci- 
dent become too great. 

In order to obtain better leverage and more perfect con- 
trol over the escape of the gas than is needed for the pur- 
poses for which the cylinders are ordinarily used, it is neces- 
sary to lengthen to about 25 cm., in whatever way seems 
best, the handle of the key which opens the escape-valve. 

The first time the cylinder is used for freezing a little water 
may escape, causing considerable sputtering. It is important 
that the water should all be gotten rid of. In freezing, the 
valve should be turned carefully, so that the gas may escape 
slowly and evenly. Pieces of tissue can easily be frozen in 
a few seconds, but it is much better to freeze the tissue neither 
too rapidly nor too hard, otherwise the sections will show on 
microscopic examination multiple parallel lines of fracture 




Fig. 78. — Knife for freezing microtome, made from the blade of a carpenter's 

plane. 

due to their being bent by the knife while still brittle. Ac- 
cordingly, when the tissue is frozen too hard, it is best to 
wait until it thaws a little, or else to soften the surface each 
time just before cutting a section by rubbing over it the tip 
of a finger moistened in water or salt solution. Pieces of 
tissue for freezing should not be over 2 to 4 mm. thick. Al- 
cohol specimens must first be thoroughly freed from spirit 
by soaking in running water for some time, usually several 
hours. 

The freezing-box of the microtome should be stronger 
than when intended for the use of ether. An excellent 
microtome designed for the use of carbon-dioxid has recently 
been put on the market by Bausch & Lomb. 

For cutting frozen sections the blade of a carpenter's plane 
mounted in a wooden handle (Fig. 78) will be found very 
serviceable and easy to sharpen. 



HISTOLOGICAL METHODS. 



209 



Celloidin Microtome. — There are two types of celloid- 
in microtomes — one in which the object is raised by a screw, 
a second in which the object is raised by being moved up an 
inclined plane. The first type of machine is the better, for 
two reasons : the screw affords greater accuracy in the even 
elevation of the object than is possible with an inclined 
plane, and the object remains at all times in the same rela- 
tive position with regard to the knife, so that an equally long 
sweep of the blade can be obtained for every section. An 
excellent instrument of this type is made by Bausch & Lomb 
(Fig. 79). For practical work it is much to be preferred to 




Fig. 79. — Large laboratory microtome. 



the elaborate Schiefferdecker-Becker microtome, designed 
for cutting sections under alcohol. 

A new and wholly original microtome, in which the knife 
remains fixed and is clamped at both ends, while the object- 
holder, which is raised by a screw, moves back and forth be- 
neath the knife, has just been designed by Dr. C. S. Minot and 
is being manufactured by Bausch & Lomb (Fig. 80). It is 
intended both for celloidin and for paraffin work. When but 
one instrument can be afforded, it is believed that this model 
will be found the most serviceable for both kinds of work. 

A drop-bottle on an elevated stand, with screw arrange- 

14 



210 



PATHOLOGICAL TECHNIQUE. 



ment for regulating the amount of alcohol, is the most con- 
venient method for keeping the object and the knife wet 
while cutting ; 80 per cent, alcohol should be used. 




Fig. 80. — Minot's latest microtome. 

Paraffin Microtome. — Although paraffin sections can 
be cut on a celloidin microtome, it is preferable to have an 
instrument designed for the purpose. The Minot ribbon 
microtome (Fig. 81), especially the latest and heaviest model, 
can be thoroughly recommended. It is manufactured in this 
country by the Franklin Educational Supply Co., which also 
furnishes with it an excellent heavy, biconcave knife. 

Paraffin Bath. — The best bath for keeping paraffin at a 
constant temperature is a thermostat of suitable size with 
hot-water jacket, such as is used for growing cultures of 
bacteria. The paraffin is kept in it on shelves in glass dishes 
of various sizes. The advantages of this method over the 
old way of using copper cups set into the top of a water- 
bath are that the paraffin is kept absolutely free from dust, 
each worker can have his own set of dishes, and the smallest 
bits of tissue can be readily found in them, because they are 
transparent. 

A paraffin melting at 50 C. will be found convenient for 



HISTOLOGICAL METHODS. 



211 



use throughout the year if the laboratory is kept fairly warm 
in winter. Many workers, however, prefer one paraffin melt- 
ing at 45 C. for winter, and another melting at 48 ° C. for 
summer. 

A preliminary bath of soft paraffin is wholly unneces- 
sary, and only prolongs the objectionable stage of heating. 
The regulator should register only one or two degrees above 
the melting-point of the paraffin. 

Paraffin should be melted and decanted or filtered before 
use, as it often contains foreign material. When hot it runs 




FIG. 81. — Minot's paraffin microtome. 



through an ordinary filter without trouble. A hot-water 
jacket to the funnel is not at all necessary. 

Vulcanised Fiber. — For mounting celloidin prepara- 
tions nothing is so poor as cork, although it has been in use 
for years. The chief objections to it are that it does not fur- 
nish a rigid support to the imbedded object ; that, unless 
weighted, it floats in alcohol with the specimen downward ; 
and that it yields a coloring material which stains both the 



212 



PA THOL O GICA L TE CHNIQ UE. 



alcohol and the specimen. Wood is not much better, 
although, of course, much firmer. Glass blocks have been 
proposed, and might do fairly well if there did not exist an 
ideal substance — viz. vulcanized fiber. This can be obtained 
in boards or strips, preferably -§- or -| inch in thickness and 
sawn to any desired dimensions. It is perfectly rigid, is 




Fig. 82. — Blocks of vulcanized fiber. 

heavy enough to sink specimens to the bottom of the jar in 
an upright position, is unaffected by alcohol or water, except 
that the surface "swells and softens very slightly, is light red 
in color, so that it is easily written on with a lead pencil, gives 
off no coloring material, and is practically indestructible. 
Two or three parallel cuts, 1 to 2 mm. in depth, should 




FIG. 83. — Diagram of the direction of the movements in honing. 

be sawn into the upper surface of each block, so as to give 
the celloidin a firm hold. 

Knives. — The knives for both the celloidin and the 
paraffin microtomes should be heavy and not too long, so as 
to afford as great rigidity as possible ; they should be bicon- 
cave, so that they may be easily sharpened. It is important 
that every one who does much work in a pathological labor- 



HISTOLOGICAL METHODS. 213 

atory should learn to sharpen his own knives. The requisite 
skill is not difficult to acquire, and the time spent in learning 
is fully compensated for by the ability always to have a sharp 
knife when it is wanted. For honing a knife either a fine 
water-stone or a glass plate with diamantine and Vienna 
chalk may be used. In honing, the edge of the knife is for- 
ward and the motion is from heel to toe. The knife should 
always be turned on its back, and the pressure on it should 
be at all times rather light. 

In stropping, the movement is reversed. The back of the 
knife necessarily precedes the edge, and the motion is from 










Fig. 84.— Diagram of the direction of the movements in stropping. 

toe to heel. The direction of the movements in honing and 
stropping is best illustrated by the diagrams (Figs. 83, 84). 

Running water for washing out specimens which have 
been fixed in Flemming and other solutions is most easily 
supplied by having a water-pipe, furnished with numerous 
cocks 5-10 cm. apart, run horizontally over a slightly slop- 
ing shelf adjoining the sink. Attached to each cock is a 
rubber tube, with a glass tube in the end of it long enough 
to reach to the bottom of the jar (Fig. 85). By this arrange- 
ment the amount of water supplied to each specimen can be 
easily regulated. 

Slides should be of colorless glass with ground edges. 
The English form, measuring 1 X 3 inches (76 X 26 mm.), is 



214 



PA THOL GICA L TE CHNIQ UE. 



to be preferred for ordinary use. Occasionally broader slides 
are needed. 

Cover-slipS should be square or oblong according to the 
shape of the specimen. Most dry lenses are adjusted for 
cover-glasses measuring 16 or ijfi in thickness, so that if 
possible no cover-slips ranging outside of 15 to 18/* should 
be used. With an oil-immersion the exact thickness is not 
quite so important. 

Slides and cover-slips are cleaned by dipping in alcohol 




FIG. 85. — Large laboratory sink 



, showing adjoining shelf and arrangement for 
running water. 



and wiping dry with a soft crash towel or old linen handker- 
chief. 

To clean old slides place them in waste alcohol until the 
cover-slips can be easily removed. The slides and cover- 
slips are then treated separately with nitric acid. A 10 per 
cent, solution is usually sufficient, but occasionally the strong 
acid will be found necessary. A thorough washing in run- 
ning water, followed by alcohol, completes the process. 
Alkalies are not so good for cleaning purposes, because 
they attack the glass. 

Staining Dishes. — Watch-glasses are not satisfactory, 



HIS TO L O GICAL ME THODS. 



215 



on account of their instability. Concave dishes with flat 
bottoms are much better for ordinary use, and can be ob- 
tained of several patterns. They should be large enough to 
hold 25 c.c. of fluid. The Syracuse solid watch-glasses are 
very good dishes of this shape. 

Slender dishes (Fig. 86) of various sizes will be found use- 
ful for many purposes. 








1111 i; r 



FIG. 86.— Stender dishes. 



c~ 



Sectional view. 



Oblong rectangular Petri dishes are very convenient for 
staining preparations mounted on the slide. 

Steinaclis sieve-dish is valuable where a number of sections 
are to be stained in the same manner. 

Large concave dishes holding 100 c.c. will be found the 
most convenient for holding frozen sections of fresh tissue, 
because a slide can be dipped into them and under the 
sections. 

Metal Instruments. — Spatulas of different sizes are 




Fig. 87.— Spatula. 

needed. They should be thin, smooth, and large enough, 
so that a section will not curl over the edge (Fig. 87). 
The best instrument for transfering sections under all cir- 



2l6 PATHOLOGICAL TECHNIQUE. 

cumstances is a piece of platinum wire mounted in an ordi- 
nary screw needle-holder. It is pliable and can be bent to 
any shape, will not break like a glass needle when dropped, 
and is not affected by acids. Ladies' hat-pins form a cheap 
but serviceable substitute. They are readily bent to any 
desired shape by heating. Forceps, scissors, scalpels, and 
many other instruments required in microscopical work do 
not need any special mention. 

Bottles. — For cover-slip work and for staining on the 
slide dropping-bottles will be found extremely convenient. 
The patent T. K. pattern of 50 c.c. capacity is probably the 
best form and size. 



EXAMINATION OF FRESH MATERIAL. 

Fresh tissues may be examined either in teased prepara- 
tions or in sections. 

Teased preparations are made by cutting out a very small 
bit of the tissue in question and dividing it as finely as pos- 
sible, by means of two sharp, clean needles, on a slide in a 
drop or two of some indifferent fluid, such as the normal 
salt solution. Teased preparations are often made, for in- 
stance, of the heart-muscle when fatty degeneration is sus- 
pected. If the tissue is soft, the cells are easily obtained by 
simply scraping the cut surface with the edge of the knife. 

Sections ef fresh tissues can be made with a razor or with 
a double knife, but much the better way, at least for general 
diagnostic purposes, is to use frozen sections, which can be 
very quickly and perfectly made with the freezing microtome. 
The fresh sections are put into salt solution in a glass dish 
large enough to permit of a slide being dipped into it, so 
that a section can be floated and spread out evenly on its 
surface. The slide is then carefully raised, the excess of fluid 
wiped off, and a cover-slip put on. 

If it is desired to stain the section, a few drops of Loffler's 
methylene-blue solution are poured over it after it is spread 
evenly on the slide. In a few seconds the coloring fluid is 



HISTOLOGICAL METHODS. 217 

thoroughly washed off with salt solution, a cover-slip put on, 
and the section examined in the salt solution. If sections of 
fresh tissues are put directly into a staining fluid in the ordi- 
nary manner, they pucker up and do not stain evenly. 

Fresh preparations are often treated with chemicals for 
various purposes. Of these chemicals, acetic acid is the 
most generally useful in pathological work. It shrinks the 
nuclei and renders their outlines more distinct. It swells 
connective tissue, making it more transparent, so that the 
elastic fibers which are unaffected stand out distinctly. It 
precipitates mucin and dissolves or renders invisible the al- 
buminous granules so abundantly present in the protoplasm 
in the cloudy swelling of various organs in disease. Its 
main use as a reagent for fresh tissues is to demonstrate 
fat and to differentiate that substance from albuminous gran- 
ules. 

Acetic acid is ordinarily used in a 1 to 2 per cent, aqueous 
solution, a few drops of which are placed at one edge of the 
cover-slip, and then drawn beneath it by placing a piece of 
filter-paper on the opposite side. If in a hurry, however, 
stronger solutions, or even glacial acetic acid, may be used. 
Other reagents are of less importance, but are occasionally 
used. 

Osmic acid is sometimes employed in a 1 per cent, aque- 
ous solution to demonstrate fat, which it stains brown to 
black. 

Hydrochloric acid in a 3 to 5 per cent, solution is used to 
demonstrate calcification. Phosphate of lime is simply dis- 
solved, while from carbonate of lime bubbles of carbon- 
dioxid (C0 2 ) are set free. 

Indifferent Fluids. — Fresh tissues are usually examined 
in normal salt solution, a t 6 q- per cent, solution of common 
salt in water. It has the advantage over water that tissues 
do not swell up so much in it, blood-globules are unaffected, 
and the finer structures are better preserved. A very few 
drops of Lugol's solution added to the stock-bottle of 
salt solution will be found useful in preventing the growth 
of mould. 



2l8 PATHOLOGICAL TECHNIQUE. 

Serous fluids, such as hydrocele fluid, are occasionally 
used. Artificial serum is made by adding I part of egg- 
albumin to 9 parts of normal salt solution. 

Macerating fluids are little used in pathology. Occa- 
sionally, however, when tissues are tough, so that they cannot 
be readily teased apart, they are macerated in certain fluids 
which dissolve the substances that hold the different elements 
together. The reagents most commonly used are the fol- 
lowing : 

1. Ranvier's one-third alcohol is made by taking I part of 
96 per cent, alcohol and 2 parts of water ; twenty-four hours 
are usually enough. 

2. Very dilute solutions of chromic acid are recommended 

— riro to fp °f I P er cent - 

3. j j per cent. Caustic Potash. — Tissues are macerated in 
a few minutes to one hour : they must be examined in the 
same fluid, because the cells are destroyed if the solution is 
weakened. 

Examination of Fluids. — Small fragments of tissue 
should be picked out with forceps. If much blood is ad- 
herent, wash the tissue well in salt solution. When the cell- 
ular elements are few in number they are obtained with a 
pipette, just as in urine-work, after allowing them to settle 
at the bottom of the glass. A centrifugal machine will be 
found of great service when the sediment is slight. 



INJECTIONS. 

Injections are not much used in pathology. The process 
is an art that requires much patience and considerable ex- 
perience. The purpose of an injection is to render vessels 
and vessel-walls more visible than under ordinary circum- 
stances. Transparent, deeply-colored fluid mixtures are 
used which will become hard in the vessels. Some injec- 
tion-masses are employed cold, others warm. The warm 
injection-masses contain gelatin, and are much more trouble- 
some to use, but give much the more perfect results. For 



HISTOLOGICAL METHODS. 219 

coloring the mass carmine is the best material, because it is 
a permanent color. 

The instruments required are cannulas of various sizes 
and a syringe, or, better still, a constant-pressure apparatus. 

When a warm injection-mass is used the bottle containing 
the mass must be placed in a water-bath and kept at a tem- 
perature of about 45 C. The organ or animal to be in- 
jected must likewise be placed in a water-bath of the same 
temperature. 

It is very important that in connecting the end of the tube 
carrying the injection-mass with the cannula inserted in the 
vessel no air-bubbles shall enter. When blood-vessels are 
to be injected it is advisable to wash them out first with 
normal salt solution. 

Cold Injection-masses. — i. Blue Coloring Mass. — 

Soluble Berlin blue, 1 ; 

Distilled water, 20. 

2. Carmine Injection-mass (Kollmann). — Dissolve 1 gram 
of carmine in 1 c.c. of strong ammonia plus a little water ; 
dilute with 20 c.c. of glycerin. To this solution add 1 gram 
of common salt (NaCl) dissolved in 30 c.c. of glycerin. 
To the whole solution add an equal quantity of water. 

Warm Injection-masses. — i. Berlin Blue. — Warm the 
solution of Berlin blue given above, and add it, with con- 
tinual stirring, to an equal quantity of a warm, concentrated 
solution of gelatin prepared as follows : Allow clean sheets 
of the best French gelatin to swell up for one to two hours 
at room-temperature in double the quantity of water. Then 
dissolve them by warming gently over a water-bath. Filter 
the combined solution through flannel. 

2. Carmine-gelatin Mass. — This is by all means the best 
injection-mass to use, because it is permanent, but it is very 
difficult to prepare. 

Dissolve 2 to 2.5 grams of best carmine in about 15 c.c. 
of water, to which just enough ammonia is added, drop by 
drop, to effect the solution. Filter the fluid obtained, and 



220 PATHOLOGICAL TECHNIQUE. " 

add it, with continual stirring, to a filtered warm, concen- 
trated solution of gelatin (prepared as above) over the water- 
bath. Then add acetic acid slowly until the color changes 
to a bright-red shade. The exact amount desired is when 
the solution loses its ammoniacal odor and has a peculiar 
sweetish aroma free from acid. Examined under the micro- 
scope, no granular precipitate of carmine should appear. If 
too much acetic acid has been added, so that the carmine is 
precipitated, the mass must be thrown away and a new lot 
prepared. 

Organs which have been injected with a cold mass are 
placed directly in 80 per cent, alcohol. After a few hours 
they are to be cut up into pieces that are not too small. 
After a warm injection-mass the organ or animal is placed 
first in cold water to hasten the solidification of the gelatin, 
and then transferred to 80 per cent, alcohol. Masses already 
prepared for injecting cold or warm can be obtained from 
Gruebler. 



FIXING REAGENTS. 



The various reagents used for the preservation of fresh 
tissues possess the properties of penetrating, killing, fixing, 
hardening, and preserving in different degrees. Of these 
properties " fixing " is the most important, and to a certain 
extent implies or includes the others. The term " fixative " 
has been used more particularly, perhaps, for reagents which 
preserve faithfully the various changes of the nucleus in 
karyomitosis. In a broader sense, however, it refers to the 
faithful preservation of any tissue-element or pathological 
product, and of the chemical properties peculiar to that ele- 
ment or product. A good fixative is a reagent that pene- 
trates and kills tissues quickly, preserves the tissue-elements, 
and particularly the nuclei, faithfully in the condition in 
which they are at the moment when the reagent acts on 
them, and hardens or so affects them that they will not be 
altered by the various after-steps of staining, clearing, and 



HISTOLOGICAL METHODS. 221 

mounting. Most fixatives are mixtures of different reagents 
so combined that all the desirable properties may be present 
in as large a degree as possible. 

The choice of the proper fixing reagent for a given tissue 
is often difficult, and must depend largely on the nature of 
the pathological lesions present or suspected, and on the 
purposes for which the tissue is preserved. For diag- 
nosis, for general bacteriological study of tissues, and for 
many valuable and important chemical reactions alcohol 
is to be preferred to any other reagent. Although by 
no means an ideal fixative, it will be found exceedingly 
useful. 

For finer histological study it is important to preserve val- 
uable tissue in some more perfect fixative than alcohol. 
Zenker's and to some extent Orth's fluid will be found the 
most generally useful. Flemming's solution is especially to 
be recommended for the study of renal lesions with fatty 
degeneration. For general pathological work, aside from 
the nervous system, these four fixatives will be found the 
most valuable. 

It is strongly advised that pieces of tissue in all important 
cases be hardened both in alcohol and in Zenker's fluid — 
in alcohol for bacteria and for chemical reactions ; in the 
other for bacteria, nuclear figures, blood, and general histo- 
logical study. For special investigations other fixatives are 
sometimes desirable. 

Tissues fixed in alcohol or in a solution of formaldehyde 
may remain as long as desirable in those fluids. Tissues 
hardened in most of the other fixatives must be transferred, 
after thorough washing in water, to alcohol for preservation. 
It is usually recommended to pass the specimens through 
graded alcohols, either through 30, 60, 90, and 96 per 
cent., or through 50, 70, and 96 per cent., allowing them to 
remain from a few hours to a day in each strength. For 
most purposes it will be found sufficient to transfer the 
specimens directly from water to alcohol of 70 to 80 per 
cent, in which they may remain until it is desired to imbed 
them. 



222 PATHOLOGICAL TECHNIQUE. 

Alcohol extracts chrome salts from tissues hardened in 
solutions of them. As these salts are precipitated in the 
alcohol under the action of light, it is desirable, although 
by no means necessary, to keep all such specimens in the 
dark. 

Alcohol. — The strength of alcohol ordinarily used in 
laboratories is 95-96 per cent. Absolute alcohol is much 
more expensive. Tissues hardened in either of these strengths 
shrink a great deal. The exposed surface becomes ex- 
tremely hard, and the outer layers of the cells of tissues 
like a rabbit's kidney, for example, are as shrunken and 
flattened as though dried in the air. It is only inside of this 
hard casing, where the alcohol has penetrated more slowly 
and has been somewhat diluted by the fluid of the tissue, 
that the cells are better preserved. Moreover, this extreme 
hardening of the surface hinders the penetration of the alco- 
hol into the deeper parts. 

Tissue which is to be hardened in absolute or 95 per cent, 
alcohol should be cut into thin pieces, preferably not over y 2 
cm. thick. The volume of alcohol used for hardening should 
be fifteen to twenty times as great as the specimen, and 
should be changed after three or four hours. The tissue 
should be kept in the upper part of the alcohol by means 
of absorbent cotton, or the jar may be frequently inverted 
and the alcohol thus kept of even strength. 

The advantages of strong alcohol, 95 per cent, and abso- 
lute, are that the tissue is more quickly fixed than with 
weaker strength, and that at the same time it is made quite 
hard — a quality more necessary formerly than now when tis- 
sues are so generally imbedded. Tissues hardened in strong 
alcohol should later be transferred to 80 per cent, alcohol for 
preservation or the staining properties will gradually become 
impaired. 

For general purposes it will be found better to place tissues 
at first into 80 per cent, alcohol, which should be replaced 
in two to four hours by 95 per cent, alcohol. In this way 
less shrinkage is caused and the surface of the tissues is not 
made so hard. 



HISTOLOGICAL METHODS. 223 

Zenker's Fluid. — 

Bichromate of potassium, 2.5 grams ; 

Sulphate of sodium, 1 '' 

Corrosive sublimate, 5 

Glacial acetic acid, 5 c.c. ; 

Water, ad 100 

The solution is practically Muller's fluid saturated with 
corrosive sublimate, plus 5 per cent, of glacial acetic acid. 
It is advisable not to add the acetic acid to the stock solu- 
tion, but only in the proper proportion to the part taken for 
hardening pieces of tissue, because the acid evaporates so 
readily. 

Directions for Use. — 1. Fix tissues in the solution one to 
twenty-four hours, rarely forty-eight hours, according to 
thickness. 

2. Wash in running water twelve to twenty-four hours. 

3. Preserve in 80 per cent, alcohol until used. 

Tissues float at first in this solution, which will be found 
a most admirable general fixative. It penetrates quickly, so 
that pieces of tissue do not need to be so thin as with most 
other fixatives, but it is advisable not to let them exceed \ 
cm. in thickness. Nuclear figures, red blood-globules, and 
protoplasm are all perfectly preserved. The greatest draw- 
back to the fluid is the precipitation of mercury which takes 
place to a varying degree in the tissues. This precipitation 
may be removed by adding a little tincture of iodin (up to 
\ per cent.) to the alcohol in which the specimens are pre- 
served. As soon as the color of the iodin disappears, on 
account of its forming .a colorless, soluble compound with 
mercury, more iodin must be added until the alcohol re- 
mains stained faintly yellow. It will sometimes be found 
difficult to get rid of all the deposit even after fairly pro- 
longed treatment (two weeks) with iodin in this manner, so 
that it is sometimes necessary to treat sections, after cutting, 
with Lugol's solution for a short time. Sometimes, indeed, 
it is preferable to reserve the treatment with iodin for the 
sections only. 



224 PATHOLOGICAL TECHNIQUE. 

Zenker preparations stain slowly but beautifully in aluni- 
hematoxylin. Excellent results can also be obtained with 
eosin, followed by Unna's alkaline methylene-blue solution. 
Fuchsin and safranin stains are sometimes useful. 

Orth's Fluid. — Recently Orth has highly recommended 
as a general fixative a solution consisting of the well-known 
Miiller's fluid plus 4 per cent, of formaldehyde : 

Bichromate of potassium, 2 to 2.5 ; 

Sulphate of sodium, 1 ; 

Water, 100; 

Formaldehyde (40 per cent, solution), 10. 

The formaldehyde should be added only at the time of using, 
for in two days the solution becomes darker, and by the 
fourth day a crystalline deposit begins to take place. As 
fixation is ordinarily complete in three to four days, this 
deposit does not matter. The tissue should not be over 1 
cm. in thickness. Small pieces \ to \ cm. in thickness can 
be readily hardened in the incubator in three hours. The 
specimens should be washed thoroughly in running water six 
to twenty-four hours before placing in 80 per cent, alcohol. 

The method is particularly recommended for mitosis, red 
blood-globules, bone, and colloid material (in cystomata, 
etc.), as it gives a very good consistency to the tissues. 
Flamming* s Solution. — 

Osmic acid, 2 per cent, aqueous solution, 4 ; 

Chromic acid, 1 per cent, aqueous solution, 1 5 ; 

Glacial acetic acid, 1. 

I. Fix in the solution one to three days. 2. Wash in running 
water six to twenty-four hours. 3. Alcohol, 80 per cent. 

It is best to keep the osmic acid in a 2 per cent, solution, 
and the chromic acid in a 1 per cent, solution. The mixture 
can then be quickly made up fresh at the time it is needed. 
The best stains after hardening in Flemming are Babes' saf- 
ranin, aniline-gentian-violet, and carbol-fuchsin. 

Pieces of tissue for hardening in Flemming's solution 
should not be over 2 mm. in thickness, because it has very 
slight penetrating properties. 






HISTOLOGICAL METHODS. 225 

Hermann's Solution. — 

Osmic acid, 2 per cent, aqueous solution, 4 ; 

Platinic chlorid, 1 per cent aqueous solution, 15 ; 

Glacial acetic acid, 1. 

This modification of Flemming's solution is, perhaps an even 
better fixative than the model on which it is based, but is 
more expensive. It should be employed in the same manner. 
Pianese's Solution. — 

Chlorid of platinum and sodium, 1 per cent. 

aqueous solution (platinic), 15 c.c. 

Chromic acid, \ per cent, aqueous solution, 5 " 
Osmic acid, 2 per cent, aqueous solution, 5 " 
Formic acid, C. P. I drop. 

Fix small pieces of tissue, not over 2 mm. thick, in the solu- 
tion for thirty-six hours. Wash in running water for twelve 
hours, then 80 per cent, alcohol. Stain paraffin sections by 
Pianese's special methods (see p. 250). 

This fixative and the special staining methods are particu- 
larly recommended for the study of karyomitosis and of the 
so-called cancer bodies. 
Rabl's Chronio-forniic Acid Solution. — 

Chromic acid, 0.33 per cent, aqueous solution, 200 ; 
Formic acid, 4 to 5 drops, 

to be added just before the solution is used. 

Directions for Use. — 1. Harden in the fixing solution 
twelve to twenty-four hours ; 2. Wash in running water 
twelve to twenty-four hours ; 3. Dehydrate in 80 per cent, 
alcohol. 

Rabl used after this fixative a very faint stain with hema- 
toxylin, followed by safranin. 

Corrosive Sublimate.— Use a saturated solution (made 
by heat) in normal salt solution. The addition of 5 per cent, 
of glacial acetic acid is sometimes advisable. 1. Harden thin 
pieces of tissue (2 to 5 mm.) for one to six hours ; 2. Wash in 
running water twenty-four hours ; 3. Preserve in 80 per cent, 
alcohol. 
15 



226 PATHOLOGICAL TECHNIQUE. 

An even' better method is, perhaps, to transfer the tissue 
directly from the corrosive-sublimate solution to 70 per cent, 
alcohol, to which enough tincture of iodin is added to give 
it a light-red color. When the color due to the iodin dis- 
appears more of the tincture must be added until a light 
color of iodin becomes permanent. 

Tissues hardened in corrosive stain quickly and brilliantly 
in nearly all staining solutions. It is the only fixative after 
which the Heidenhain-Biondi triple stain gives good results. 

Formaldehyde. — The gas formaldehyde (HCOH) is 
soluble in water to the extent of 40 per cent. Solutions of 
this strength are manufactured by different commercial houses 
under the names of formaline, formol, and formalose. The 
best strength of formaldehyde to use for fixing tissues is a 
4 per cent, solution ; that is, 10 parts of the aqueous 40 per 
cent, solution, no matter what name is given to it, to 90 
parts of water — or, better still, perhaps, of normal salt 
solution. 

This new fixing reagent penetrates very quickly. Its 
hardening action is not understood. It does not precipitate 
albuminous bodies, but makes them quite firm. It also 
hardens nerve-sheaths, acting toward them and red globules 
like the chrome salts. Formaldehyde is very useful for pre- 
serving gross specimens, because it gives them a rather 
tough, elastic consistency, and preserves the normal colors 
better than other hardening fluids, and also the transparency 
of many parts, such as the cornea. In histological work it 
has been found most useful, so far, for the preservation of 
nervous tissue. 

Sections of ordinary tissues not over 1 cm. thick are 
hardened in twenty-four hours. They may then be trans- 
ferred to alcohol, or may remain indefinitely in the formal- 
dehyde. Large pieces require more time. Formaldehyde 
is much used for hardening tissues quickly, so that frozen 
sections can be cut and permanent preparations stained and 
mounted in the course of a few hours. Thin pieces are suf- 
ficiently hardened in one to three hours. They may be 
frozen directly in the formaldehyde solution or in water. 



HISTOLOGICAL METHODS. 227 

Almost any stain is applicable after the sections have been 
washed in water and treated for a short time with alcohol. 

Although formaldehyde is an excellent fixative from the 
point of view of killing quickly, it does not seem to pre- 
serve tissue-elements so that they will not later undergo 
changes when treated with various reagents. For this reason 
it is best combined with some more purely hardening re- 
agent, as, for example, bichromate of potassium in Orth's 
solution. Tissues such as muscle or the contents of a mul- 
tilocular cystoma which have been made very hard by the 
fixing reagent used, can be softened, even when mounted in 
celloidin, so that they will cut perfectly, by placing in a 4 per 
cent, solution of formaldehyde for twenty-four hours. 

Boiling - . — Boiling precipitates the soluble albumin in 
tissues as a granular material which can be readily recog- 
nized. The method is used particularly for the demonstra- 
tion of albumin in renal diseases and in edema of the lungs. 
By means of boiling the quickest permanent mounts of 
tissues can be obtained. The method is not advocated, on 
account of the shrinkage caused by the heat, but will some- 
times be found useful. 

Small pieces of tissue not over 1.5 cm. in diameter should 
be dropped into the boiling water for one half to two 
minutes ; cool quickly in cold water and make frozen sec- 
tions, or put into 80 per cent, alcohol. Any stain can be 
used; methylene-blue will be found excellent. 

Miiller's Fluid.— 

Bichromate of potassium, 2 to 2.5 grams ; 

Sulphate of sodium, 1 " 

Water, 100 c.c. 

Harden tissues six to eight weeks. Change the fluid daily 
during the first week ; once a week thereafter. Ordinary 
tissues are then washed in running water over night before 
being placed in alcohol. Nervous tissue is transferred 
directly from the fluid to the alcohol. 

This famous hardening solution seems destined before 
long to give way entirely to better fixatives. It hardens 
tissues slowly, evenly, and with little or no shrinkage, but it 



228 PATHOLOGICAL TECHNIQUE. 

is a poor nuclear fixative, and does not encourage any great 
variety of stains. For ordinary tissues it will undoubtedly 
be replaced by Zenker's or Orth's fluid, both of which fix 
very quickly, besides having all its good qualities. For 
nervous tissues formaldehyde followed by other solutions 
of the chrome salts is a great deal quicker and better. 
Marches Fluid. — 

Midler's fluid, 2 parts ; 

Osmic acid, I per cent, aqueous solution, I part. 

Place small pieces of tissue in the mixture for five to eight 
days, wash thoroughly in running water, and harden in 
alcohol. For its application to degenerated nerve-fibers see 
page 325. 
Erlicki's Fluid.— 

Bichromate of potassium, 2.5 grams ; 

Sulphate of copper, 1. 

Water, 100 c.c. 

Hardening is quicker than with Muller's fluid, requiring 
eight to ten days, otherwise the treatment is the same. 



DECALCIFICATION. 

Tissues which are to be decalcified should be sawn with a 
fine hair-saw into thin slices, so that they will decalcify 
quickly. It is usually desirable to saw the tissue into pieces 
of proper size for imbedding in celloidin. Very dense bone 
ought not to be over 2 or 3 mm. thick ; softer tissues do not 
need to be thinner than 4 to 6 mm. In cutting sections after 
decalcifying and imbedding it is necessary to throw away the 
first half-dozen sections or so, because the tissue is so lace- 
rated to a slight depth by the movement of small fragments 
of bone in the process of sawing as to be useless for micro- 
scopic purposes. The extent of the decalcification can be 
tested at any time by thrusting a needle into the tissue. 

The following steps in the decalcification of tissues must 
be carefully borne in mind : 



HISTOLOGICAL METHODS. 220, 

1. The tissues must first be thoroughly hardened. The 
three most useful reagents for this purpore are alcohol, 
Zenker's and Orth's fluids. After the two latter reagents the 
tissues must have been washed thoroughly in water and 
placed in alcohol for at least twenty-four hours. They will 
then be ready for decalcification. 

2. The decalcifying fluid must be used in large amounts, 
and if necessary be frequently changed. 

3. After decalcification the tissues must be thoroughly 
washed in running water for twenty-four hours to get rid of 
every trace of the acid. 

4. The tissues finally must be hardened again in alcohol. 

Of the various agents used for decalcifying bone, ni- 
tric, hydrochloric, chromic, picric, trichloracetic acids, etc., 
the most important is nitric acid. It acts quickly, without 
swelling the tissues or attacking injuriously the tissue-ele- 
ments, and does not interfere to any marked degree with any 
subsequent staining process. Red blood-globules will be 
found uninjured in tissues hardened in Zenker's fluid even 
after remaining four days in 5 per cent, nitric acid. This 
acid is used in dilute solution alone or in combination with 
phloroglucin. 

Directions for Using Nitric Acid. — i. Decalcify in 
large quantities of a 5 per cent, aqueous solution of nitric acid, 
changing the solution every day for one to four days. 2. 
Wash twenty-four hours in running water to remove every 
trace of acid. 3. Harden in 80 per cent., and then 95 per 
cent., alcohol. Imbed in celloidin. 

Phloroglucin and Nitric Acid. — Phloroglucin is not 
a decalcifying agent, but is added to nitric acid to protect the 
tissues while allowing a stronger solution of the acid to be 
used than would otherwise be possible. The solution is 
prepared by dissolving 1 gram of phloroglucin in 10 c.c. of 
nitric acid. Solution takes place quickly, with generation of 
considerable heat. The fluid is reddish brown at first, but 
becomes light yellow in the course of twenty-four hours. 
Dilute with 100 c.c. of a 10 per cent, solution of nitric acid. 
This gives nearly a 20 per cent, solution of nitric acid. The 



230 



PA THOLOGICAL TECHNIQ UE. 



process of decalcification in this fluid is extremely rapid ; a 
few hours only, as a rule, are required. It is not advisable 
to dilute the solution by the simple addition of water, but 
by the use of less acid, because the phloroglucin must be 
present to the amount of I per cent, or it will not protect 
the tissues so well. 

The following slower-acting solution may be found useful : 

Phloroglucin, I ; 

Nitric acid, 5 ; 

Alcohol, 70; 

Water, 30. 

A rather deep single stain with alum-hematoxylin (either 
aqueous solution or Delafield's) will usually be found to give 
the best results with tissues decalcified with nitric acid. It 
is very important to leave the sections after staining in a 
large dish of water over-night, otherwise the stain will not 
be so sharp and clear. 

Picric Acid. — A saturated aqueous solution containing 
an excess of crystals is sometimes used for decalcifying. It 
has no injurious action on tissues, but is extremely slow, fre- 
quently requiring months. Fresh tissues may be placed 
directly in the solution, which hardens and decalcifies at the 
same time. Instead of being washed out in water, in which 
they would macerate, the pieces of tissue are placed directly 
in 70 per cent, alcohol to remove the acid. 

Trichloracetic Acid. — A 5 per cent, solution of this 
acid has lately been recommended for the decalcification of 
bone and teeth. It acts more slowly than nitric acid, and 
seems to possess no advantages over it. Tissues must be 
washed out in running water, as after nitric acid. 



IMBEDDING PROCESSES. 

Sections of hardened tissues can be cut with a razor by 
hand, or with a microtome knife after fastening the specimen 
in the microtome clamp either directly or between pieces of 
amyloid liver. Fair sections of firm tissues can often be ob- 



HISTOLOGICAL METHODS. 23 1 

tained in this way. Thinner sections can be gotten by means 
of the freezing microtome, but these methods are all open 
to the objection that unless the tissue is very cohesive por- 
tions of it are likely to fall out of the sections. 

The best results would, therefore, naturally be expected 
from some imbedding process, employing a substance to in- 
filtrate the tissues thoroughly and to hold the different parts 
in proper relative position even in the thinnest sections. 

The two substances in common use for this purpose are 
celloidin and paraffin. Each has its advantages and disad- 
vantages. Neither can be employed in pathological histology 
to the exclusion of the other. Paraffin affords the thinnest 
sections, but they must be small if the best results are de- 
sired, and cannot be properly handled except when fastened 
to the slide. Hard tissues like muscle, and tissues of vary- 
ing consistency like skin, are cut with great difficulty by the 
paraffin method. Staining is rather simpler than after im- 
bedding in celloidin. 

On the other hand, tissues of almost any consistency or 
size can be cut by the celloidin method, which is also capable 
of furnishing very thin sections. 

Both methods of imbedding should be learned and used. 
Celloidin sections are especially good for general work, for 
studying the extent and relations of pathological processes, 
and for much of the finer histological work. Paraffin sec- 
tions are better for the finest details of processes — for special 
work on special tissues. 

Celloidin. — Schering's celloidin is the best preparation 
of gun-cotton (pyroxylin) to use. It is sold now in a con- 
venient granular form in small bottles. It keeps well, dis- 
solves somewhat slowly, and gives a fairly transparent im- 
bedding mass which is firm and tough, so that very thin 
sections can be cut. Other forms of gun-cotton are not so 
reliable ; they often contain impurities and do not yield so 
firm an imbedding mass. 

Imbedding in Celloidin. — The process consists in 
soaking the tissues for twenty-four hours to a number of 
days in two different solutions of celloidin. The two solu- 



232' PATHOLOGICAL TECHNIQUE. 

tions are spoken of as thin and thick celloidin. To make 
thick celloidin 30 grams of the dry celloidin are dissolved 
in 500 c.c. of a mixture of equal parts of ether and absolute 
or 95 per cent, alcohol. This gives a 6 per cent, solution. 
Diluted with an equal amount of the ether-and-alcohol mix- 
ture, it forms thin celloidin. 

The steps of the imbedding process are as follows : Pieces 
of tissue which have been properly fixed and finally pre- 
served in 80 per cent, alcohol are first to be cut up with in- 
telligence. They should rarely be over 4 to 8 mm. thick ; 
for most purposes 2 mm. will be found sufficient. Pieces of 
this thickness will furnish several hundred sections, will im- 
bed more quickly than larger masses, and will be more rigid 
when mounted on a block. They should never be broader 
or longer than is necessary to show the whole of the process 
under study. Very thin celloidin sections cannot usually be 
obtained with tissues over i| to 2 cm. square, and smaller 
dimensions are preferable. Beginners usually imbed larger 
pieces than are necessary. 

The trimmed pieces of tissue are first hardened and de- 
hydrated for twenty-four hours in 95 per cent, alcohol ; then 
soaked in equal parts of alcohol and ether for the same 
length of time to prepare them for the thin celloidin. In the 
latter they remain at least twenty-four hours, preferably for 
a number of days if at all thick, for in this solution occurs 
most of the infiltration with celloidin. Finally, the pieces are 
soaked twenty-four hours or more in the thick celloidin. 
They are then mounted on blocks of vulcanized fiber, ex- 
posed to the air for two or three minutes till the surface 
hardens a little, and placed in 80 per cent, alcohol for six to 
twenty-four hours to allow the celloidin to harden. 

Briefly summed up, the steps of imbedding in celloidin are 
as follows : 

1. 95 per cent, or absolute alcohol, twenty-four hours. 

2. Ether and 95 per cent, or absolute alcohol, aa. twenty- 
four hours. 

3. Thin celloidin, twenty-four hours to one or more weeks. 

4. Thick celloidin, twenty-four hours to one or more weeks. 



HISTOLOGICAL METHODS. 233 

5. Mount on blocks of vulcanized fiber: dry a minute or 
two in the air. 

6. Harden celloidin in 80 per cent, alcohol, six to twenty- 
four hours. 

Although absolute alcohol is perhaps preferable for dehy- 
dration and for mixing with the ether in the above mixtures, 
95 per cent, alcohol will be found to answer all requirements. 
The second step may be omitted, especially after dehydration 
in absolute alcohol, if time is pressing. 

Instead of mounting directly from the thick celloidin, it is 
often advisable to allow the celloidin to evaporate until a firm 
mass is obtained. This is particularly true when very loose 
tissues are to be imbedded. 

The simplest method is to place the pieces of tissue, which 
have been soaking in thick celloidin, in proper position in a 
glass dish and pour thick celloidin over them. The dish is 
then covered, but not too tightly, and the ether is allowed to 
evaporate for one or more days until the proper consistency 
of celloidin is reached, so that it can be cut out in blocks 
enclosing the specimens. If the ether evaporates too rapidly, 
place a large dish or a bell-jar over the covered dish. Mount 
the blocks, after they have been cut out and trimmed, by 
dipping the bases in thick celloidin and then pressing them 
on to blocks of vulcanized fiber. In two or three minutes 
they can be placed in 80 per cent, alcohol. After the cel- 
loidin mounts have been in 80 per cent, alcohol for six to 
twenty-four hours the celloidin is of the proper consistency 
for cutting. It is best to take a sharp knife or an old razor 
and trim the top of the celloidin down to where the first 
good section of the specimen can be cut ; this will save con- 
siderable wear on the microtome knife. 

In cutting, the microtome knife should be fastened very 
obliquely, so that as much of the edge of the knife as pos- 
sible shall be used in making each section. The surface of 
the knife should be kept well wet with 80 per cent, alcohol, 
preferably from an overhanging drop-bottle. 

If the sections curl, as often happens when they are thin, 
they are best flattened by unrolling them on to the surface 



234 PATHOLOGICAL TECHNIQUE. 

of the knife with a camel 's-hair brush just before the last 
edge of celloidin is cut through, as this serves to keep them 
fixed in place during the process. This method can be 
used when the simple transferring of sections from alcohol 
to water is not sufficient to uncurl them. 

Celloidin sections can be stained by nearly all methods, 
without the necessity of removing the celloidin. When 
necessary, however, the celloidin is readily removed by pla- 
cing the sections from absolute alcohol in oil of cloves or in 
the alcohol-and-ether mixture for five or ten minutes, and 
then passing them back through absolute into ordinary 
alcohol. 

To Attach Celloidin Sections to the Slide. — A celloidin sec- 
tion can be fairly well attached to a slide by transferring it 
from water to a slide freshly washed in alcohol and dried 
with a cloth. The section is then to be firmly blotted with 
filter-paper so as to apply it closely to the slide and to re- 
move all wrinkles. It should not be allowed to dry. A 
section treated in this way will ordinarily stand considerable 
manipulation without becoming loose. 

Celloidin sections can be more securely attached by trans- 
ferring them from 95 per cent, alcohol to clean slides and 
pouring over them ether-vapor from a bottle half full of 
ether. With a little practice sections can be fastened in a 
few seconds. Follow slowly along the edge of the celloidin, 
and the frills in it will soften down. Then wash the speci- 
men with 80 per cent, alcohol to harden the celloidin. 

Imbedding in Paraffin. — Paraffin imbedding is particu- 
larly useful when very thin sections are desired. To obtain 
the best results the pieces of tissue should be small, soft, 
and of uniform consistency. In pathological work it is much 
better to cut the sections and to stain them after they are 
fastened to the slide than to stain in the mass beforehand, 
because then a variety of stains may be used. A complete 
or perfect series is not so important as in embryology, but 
with a little care can be obtained. 

The first step in the preparation of hardened tissues for 
the paraffin bath is to cut them into small, thin square or 



HISTOLOGICAL METHODS. 235 

rectangular pieces, not over 1 cm. square, perhaps, for the 
best results, and not over 2 to 3 mm. thick. It should be 
stated, however, that with proper skill, a heavy, sharp knife, 
and a rigid microtome very thin paraffin sections can be ob- 
tained with tissues measuring 4X3 cm. The pieces of 
tissue are then thoroughly dehydrated by soaking first in 95 
per cent and then in absolute alcohol. From alcohol they 
are put in some substance, such as chloroform or oil of 
cedar, which has the property of mixing with alcohol and 
of dissolving paraffin. From the chloroform they are trans- 
ferred to a saturated solution of paraffin in chloroform, and 
then passed through two or three separate baths of the 
melted paraffin to get rid of every trace of the chloroform. 
If oil of cedar is used, the specimens are transferred directly 
from it into the melted paraffin. 

One advantage of the chloroform method is that the dura- 
tion in the hot paraffin, the objectionable feature of the 
paraffin method, is shortened, because the tissues are already 
somewhat infiltrated with paraffin. Another advantage is 
that the paraffin bath purifies itself, because the chloroform 
rapidly evaporates. When oil of cedar is used the paraffin 
must be renewed frequently. 

The methods of imbedding in paraffin are briefly stated as 
follows : 

Method No. 1. 

1. 95 per cent, alcohol, 6-24 hours. 

2. Absolute alcohol, 6-24 " 

3. Chloroform, 6-24 " 

4. Chloroform saturated with paraffin, 6-24 " 

5. Paraffin bath, three changes, 1- 6 " 

6. Imbed and cool quickly in cold water. 

Method No. 2. 

1. 95 per cent, alcohol, 6-24 hours. 

2. Absolute alcohol, 6-24 " 

3. Oil of cedar, two changes, 6-24 " 

4. Paraffin, three changes, 2- 8 " 

till no odor of oil of cedar. 

5. Imbed and cool quickly in cold water. 



236 PATHOLOGICAL TECHNIQUE. 

In the second method other substances than oil of cedar 
can be used, such as xylol, equal parts of oil of cloves and 
turpentine, or oil of cloves and xylol. 

For imbedding paraffin specimens metallic boxes can be 
used, or forms made round or square from strips of sheet 
lead or tin. Many prefer paper boxes, which can be made 
easily of any size desired from stiff writing-paper. 

Melted paraffin is poured into the paper box to the depth 
of about 1 cm. The pieces of tissue are then placed in the 
box with that side down from which sections are preferred. 
When all of the pieces are arranged in order with about half 
a centimeter or more between them, the box is placed on the 
surface of a large dish of cold water, on which it floats, so 
that the paraffin may cool quickly without crystallizing. 
After the paraffin has hardened the paper is removed and 
the paraffin is divided up according to the pieces in it. One 
of the blocks is then fastened to the object-holder by heating 
the latter in a flame until it will just melt the paraffin when 
the block is held in proper position against it. The holder 
is then quickly cooled in cold water. 

The upper surface of the paraffin should now be shaved 
down to the specimen. The four sides are to be carefully 
trimmed as close as possible to the specimen, but care must 
be taken to preserve always a perfect rectangular parallelo- 
gram. The holder is finally carefully adjusted in the paraffin 
microtome. 

To get good sections which will adhere to each other and 
form a ribbon the temperature of the room must be regulated 
to suit the degree of hardness of the paraffin used. An open 
window will often make all the difference needed to obtain 
good results. The harder the paraffin the warmer the room 
must be. The temperature can be raised by burning a Bun- 
sen flame near the microtome or lowered by the presence of 
a lump of ice. 

The ribbons of sections as cut, usually a slideful, are 
laid on the surface of a large dish of warm water at about 
44 C, and if necessary gently stretched so as to remove 
all wrinkles. Paint the surface of a slide with a thin layer 



HISTOLOGICAL METHODS. 237 

of Mayer's glycerin-albumin mixture, wipe off all excess with 
a towel so that only a faint layer is left, dip the slide under 
the sections, arrange them in order, lift the slide, and drain 
off the water. The slide is then placed in a slanting position 
until dry, when it is put in the incubator for two to twelve 
hours at a temperature of 54 to 6o° C. The heat coagu- 
lates the albumin, which thus attaches the sections firmly to 
the slide. 

To get rid of the paraffin in the sections they are treated 
with two or three changes of xylol, and then with absolute 
followed by 95 per cent, alcohol. 

If for any reason the celloidin-and-oil-of-cloves mixture is 
used, the paraffin is removed by means of xylol, followed by 
origanum or bergamot oil, and finally by 95 per cent, alco- 
hol, because absolute alcohol will dissolve the celloidin. 

Serial Sections by the Celloidin Method. — i. For 
Tissues in General. — With a little care perfect serial sections 
can be made by the following method, and each slide of sec- 
tions can be stained in whatever way seems best. The 
specimen is imbedded, mounted on vulcanized fiber, and 
hardened in 80 per cent, alcohol in the usual way. In cut- 
ting moisten the microtome knife with 95 per cent, alcohol. 
As the sections are cut they are drawn up on the surface of 
the knife and arranged in regular order by means of a camel's- 
hair brush until a slideful is ready. They are then drawn on 
a clean and numbered slide held against the back of the 
knife. After being carefully arranged the sections are fast- 
ened to the slide by means of ether-vapor (see p. 234) poured 
over them from a half-full bottle. Care must be taken that 
every edge of the celloidin is fully softened down. The slides 
are then placed in a jar of 80 per cent, alcohol to be stained 
at leisure. 

2. Another method, often convenient where the stain is of 
little importance, is as follows : The tissue is stained, in bulk, 
in alum-cochineal or some other staining fluid that will pene- 
trate, and then imbedded in celloidin in the usual way. After 
being mounted on vulcanized fiber the specimen is hardened 
in chloroform instead of in 80 per cent, alcohol. From the 



238 PATHOLOGICAL TECHNIQUE. 

chloroform the specimen is transferred to oil of thyme. 
After it is thoroughly penetrated by the latter it is ready to 
be cut. The knife is to be moistened with oil of thyme. 
The sections as cut are arranged on the knife, and then trans- 
ferred to slides placed against the back of the knife. The 
slides covered with sections can be placed under a bell-jar as 
fast as they are ready until all are cut, because the oil of 
thyme evaporates slowly. Balsam and cover-slips can be 
added after the cutting is finished. 

3. Darkschewitsch has recently proposed a comparatively 
simple method for preparing a series of celloidin sections. 
A glass cylinder without a neck, of about the diameter of 
the specimen to be cut, is filled with alcohol. Then a series 
of circles of filter-paper is cut of a size just to fit the bottle, 
numbered in order, and wet with alcohol. Each section is 
removed from the microtome knife by pressing one of the 
paper circles upon it and drawing it off. The paper is then 
inverted so that the section is uppermost, and deposited in 
proper order in the bottle, where the series forms a column, 
each section resting upon a numbered paper. The sections 
can be kept indefinitely. When ready to stain the alcohol 
is poured off, the sections washed with water if necessary, 
and then the staining solution poured into the bottle. Other 
reagents are used in the same manner, or sections can be 
treated with the reagents in flat plates, as they do not readily 
slip off the papers. 

4. Weigert's method for a series of celloidin sections was 
designed especially for the nervous system and is rather 
complicated. The process depends on transferring the sec- 
tions as cut to narrow strips of tissue-paper. To do this 
each section as cut is arranged in proper position close to 
the edge of the knife. Then a strip of tissue-paper twice as 
wide as the section is gently placed upon it. The section 
adheres, and is removed by drawing the paper to the left 
and in an upward direction over the edge of the knife. The 
success of the process depends on having but little alcohol 
on the knife, otherwise the specimen will not stick. Each 
specimen is placed on the paper to the right of the last one. 



HISTOLOGICAL METHODS. 239 

The strips of paper when full are kept moist by being placed 
with the specimens uppermost on a moist surface composed 
of a layer of blotting-paper wet with alcohol, covered with a 
sheet of tissue-paper, and lying in a shallow dish. 

When all the sections have been cut, each strip of them 
is taken in turn and coated on both sides with a thin film of 
celloidin in the following way : A strip of sections with the 
specimens below is first pressed gently down upon the sur- 
face of a slide covered with a thin layer of celloidin. This 
fastens the sections and the paper can be removed. Then a 
thin coat of celloidin is poured over the sections and the 
slide is placed on its edge to drain. When the surface of 
the celloidin is dry, the strips can be marked by a fine brush 
dipped in methylene-blue. As soon as the slides are placed 
in the staining solution the celloidin peels off, taking the 
specimens with it. Later, the strips of specimens can be 
divided as desired. On account of their thickness they 
should be cleared, after dehydrating in 95 per cent, alco- 
hol, in a mixture of xylol 3, carbolic-acid crystals 1. 

To obtain serial sections by the paraffin method it 
is only necessary to avoid losing any of the sections from 
the ribbon as ordinarily cut. Perhaps the easiest and safest 
way is to cut long ribbons, a yard or more in length, and 
to place them on sheets of paper in proper order. They 
can then readily be divided by means of needles into short 
series of any desired number of sections, and fastened to 
numbered slides by means of albumin fixative. 



STAINING SOLUTIONS. 



Hematoxylin and Hematein Stains. — The active 
coloring agent in most hematoxylin stains is hematein, 
which is gradually formed in the ordinary solutions from 
the hematoxylin by oxidation, a process occupying a number 
of days or weeks and spoken of as " ripening." The selec- 
tive staining power of alum-hematoxylin solutions is due to 



240 PATHOLOGICAL TECHNIQUE. 

the combination of this hematein with alumina. The result- 
ing blue-colored solution is precipitated in the tissues (chiefly 
in the nuclei) by certain organic and inorganic salts there 
present, as, for instance, phosphates. 

Mayer and Unna have shown that it is possible to oxidize 
and to ripen in an instant a solution of alum and hema- 
toxylin by adding to it a little peroxid of hydrogen neutral- 
ized by a crystal of soda. 

By employing hematein or its ammonium salt, instead of 
hematoxylin, Mayer has been able to obtain immediately 
ripened solutions which compare fairly favorably with old 
and well-known solutions prepared from hematoxylin by the 
slow process of ripening. They do not stain any better, 
however, and it is doubtful if, for the present at least, they 
become generally accepted. 

Most solutions of alum and hematoxylin are not stable. 
A continuous chemical change is the formation from hema- 
toxylin, by oxidation, of hematein, which, uniting with the 
alum, gives a bluish or purplish solution. The degree of 
blueness depends largely on the freshness of the alum. As 
the solution becomes older free sulphuric acid is gradually 
formed from the alum, causing the solution to lose its bluish 
or purplish tint and to become reddish. A third chemical 
change is the continuous formation of a precipitate due to 
the further oxidation of the hematein, in consequence of 
which it is always necessary to filter alum-hematoxylin solu- 
tions just before they are used. 

More alum than is needed to combine chemically with the 
hematoxylin is always added to the solution, for the reason 
that it acts as a differential decolorizer, limiting the stain largely 
to the nuclei of the cells. As alum-hematoxylin solutions be- 
come older they stain more quickly, but also more diffusely. 
This diffuseness of staining can be counteracted by adding 
enough alum-water to make the stain precise again. A good 
alum-hematoxylin solution ought not to stain the celloidin 
in which the section is imbedded. If the celloidin stains 
more or less deeply, it shows that the solution requires more 
alum. 



HISTOLOGICAL METHODS. 24 1 

Aqueous Alum-hematoxylin Solution. — 

Hematoxylin crystals, I ; 

Saturated aqueous solution of ammonia alum, 100; 
Water, 300 ; 

Thymol, a crystal. 

The hematoxylin crystals are dissolved in a little hot water. 
The combined solution is then exposed to the light in a 
bottle lightly stoppered with a plug of cotton. The solution 
will be ripened sufficiently for use in about ten days, after 
which time it should be kept in a tightly-stoppered bottle. 
The solution is very easily prepared, gives beautiful results, 
and will keep at its best for two to three months. The pro- 
portions of alum and of hematoxylin are the same as in Del- 
afield's solution. 

Delafield's Hematoxylin. — 

Hematoxylin crystals, . 4 grams ; 

Alcohol, 95 per cent, 25 c.c. ; 

Saturated aqueous solution of ammonia 

alum, 400 " 

Add the hematoxylin dissolved in the alcohol to the alum 
solution, and expose the mixture in an unstoppered bottle 
to the light and air for three to four days. 
Filter, and add — 

Glycerin, 100 c.c. ; 

Alcohol, 95 per cent, 100 " 

Allow the solution to stand in the light until the color is 
sufficiently dark, then filter and keep in a tightly-stoppered 
bottle. The solution keeps well and is extremely powerful. 
So long as it is good the solution has a purplish tinge. 

It would seem advisable, both in this solution and in Ehr- 
lich's, to combine the alum, hematoxylin, and the water, and 
to ripen the solution for two or three weeks before adding 
the other ingredients which have a tendency to prevent oxi- 
dation. A fully-ripened solution would then be obtained 
more quickly and surely. 

16 



242 PATHOLOGICAL TECHNIQUE. 

Bhrlich's Acid Hematoxylin. — 

Hematoxylin crystals, 2 grams ; 

Absolute alcohol, 60 c.c. ; 

y ' " I saturated with 



Water, 00 V . . 

' „ [ ammonia alum. 

Glacial acetic acid, 

The solution is to be exposed to the light for a long time 
until it acquires a deep-red color. If it then be kept carefully 
stoppered, its staining powers will remain constant for years. 
The acetic acid is added to prevent the formation of insoluble 
compounds of hematein and as a decolorizer to limit the 
stain to nuclei. 

Mayer's Hemalum. — 

Hematein, or its ammonia salt, 1 gram ; 

90 per cent, alcohol, 50 c.c. ; 

Alum, 50 grams ; 

Water, I OOO c.c. ; 

Thymol, a crystal. 

Dissolve the hematein or its ammonia salt in the alcohol by 
the aid of heat, and add it to the alum dissolved in the water. 
The solution can be diluted with 20 parts of water or of 
weak alum solution. 

Mayer's acid hemalum is prepared by adding 2 per cent, 
of glacial acetic acid to the above solution. The acid stain 
is more precise than the alkaline. 

Mayer's Glycerin-alum-hematein Solution. — According 
to Mayer's latest investigations, glycerin is the only reliable 
preservative of hematein solutions. Unfortunately, it slows 
the staining power to a considerable extent and makes the 
stain less precise. He recommends the following solution 
for its keeping properties : 

Hematein, 0.4 grams 

(dissolve by rubbing up in a few drops of glycerin) ; 
Alum, 5 grams ; 

Glycerin, 30 c.c. ; 

Water, 70 " 



HISTOLOGICAL METHODS. 243 



Mayer's Muchematein. — 




Hematein, 


0.2 grams ; 


Chlorid of aluminum, 


0.1 " 


Glycerin, 


40 c.c. ; 


Water, 


60 " 



Rub up the hematein with a few drops of glycerin, add the 
chlorid of aluminum, and dissolve the mixture in the 
glycerin and water. 

Weig-ert's Alcohol Hematoxylin. — 

Hematoxylin crystals, 10 grams; 

Alcohol (absolute or 95 per cent.), 90 c.c. 

The solution ripens in a week or two to a brown color, and 
keeps perfectly for a long time. It is used only in the 
Weigert stain for myelin sheaths, for which purpose it is 
diluted at the time of using with water and combined with 
carbonate of lithium (see page 318). 

Phosphomolybdic Acid Hematoxylin (Ma/lory). — 
Hematoxylin crystals, 1.75 grams; 

\ per cent, aqueous solution of phos- 
phomolybdic acid, 200 c.c. 

The hematoxylin will dissolve almost immediately if powdered, 
or it may be dissolved in water by the aid of heat. The 
solution must be exposed to the light in a bottle plugged 
with cotton for five to six weeks before it is fully ripened. 
It will keep for several months, and can be used over and 
over. It is employed for staining the nervous system and 
connective tissue (see page 301). The solution seems to 
keep better without the addition of any antiseptic, as for- 
merly advised. 

Phosphotungstic Acid Hematoxylin (Mallory). — 

Hematoxylin, . 1 gram ; 

1 per cent, aqueous solution of phospho- 

tungstic acid, IOO c.c. 

Dissolve the hematoxylin in a little water by the aid of heat, 
and add it after it is cool to the dilute acid. The solution 



244 PATHOLOGICAL TECHNIQUE. 

has a greenish-brown, then brownish color of slight intensity. 
It is ready to use at once, keeps well, and requires no anti- 
septic. 

It is used mainly for staining neuroglia-fibers, but gives 
interesting results with elastic fibers, striated muscle-fibers, 
fibrin, and cartilage. 

Carmine Stains. — The active staining principle in car- 
mine solutions is carminic acid. In cochineal carminic acid 
is combined with an alkaline base. Carmine itself is a com- 
mercial compound containing carminic acid combined with 
aluminum and calcium. Carminic acid itself does not stain, 
but it forms compounds with certain metals, mainly with the 
aluminum contained in alum, which have selective staining 
properties. 

All of the alkaline and acid solutions made with carmine 
owe their staining properties to carminic acid combined with 
the aluminum, and perhaps also to the calcium contained in 
the carmine. 

Alum Carmine. — 

Carmine, 2 grams ; 

Alum, 5 

Water, ioo c.c. 

Boil twenty minutes, adding enough water to make up for 
that lost by evaporation. When cool, filter and add a 
crystal of thymol to prevent the growth of mould. 
Alum Cochineal. — 

Powdered cochineal, 6 grams ; 

Ammonia alum, 6 " 

Water, 1 00 c.c. 

Boil for half an hour ; add water to make up for that lost 
by evaporation. Filter and add a crystal of thymol. 
Orth's Lithium Carmine. — 

Carmine, 2.5 to 5 grams; 

Saturated aqueous solution of car- 
bonate of lithium, 100 c.c. ; 
Thymol, a crystal. 

The carmine dissolves at once in the cold solution. When 



HISTOLOGICAL METHODS. 245 

used as a counter-stain for bacteria in the Gram-Weigert 
method this solution should be carefully filtered, because 
organisms occasionally grow in it and may give rise to con- 
fusion in the stained preparations. 

Neutral Carmine. — Dissolve, without heating, 1 gram of 
best carmine in 50 c.c. of distilled water plus 5 c.c. of strong 
aqua ammoniae. Expose the fluid in an open dish until it 
no longer smells ammoniacal (about three days) ; then filter 
and put away in a bottle for future use. The odor of the 
solution will soon become bad, but the staining properties 
will remain unaffected. 

Aniline Dyes. — It is extremely important that all aniline 
dyes used in histology should be obtained, with possibly a 
few exceptions, from Grubler, either directly or from his 
authorized agents. In no other way is it possible to obtain 
with certainty the results expected. In this country Eimer 
& Amend of New York City are the chief agents for Grubler. 

Aniline dyes come in the form of a powder or as crystals, 
and most of them keep well in that condition. Methylene- 
blue for one, however, seems to be an exception. After the 
original package has been opened for a short while the dye 
loses in intensity of staining power. It is well to keep on 
hand saturated alcoholic solutions of certain of the dyes, 
because they keep well in that form, and are ready for use 
when a saturated alcoholic solution is wanted. This is par- 
ticularly true of methylene-blue, fuchsin, and gentian-violet. 

Aniline dyes are derived from either aniline or toluidin, or 
from both together. They may be regarded as salts having 
basic or acid properties. The basic colors stain cell-nuclei, 
including bacteria, for which they show a marked affinity. 
The acid colors stain diffusely. The basic dyes most com- 
monly employed in pathological histology are methylene- 
blue, fuchsin, gentian-violet, and safranin. Of the acid 
colors, eosin, picric acid, and acid fuchsin are most in use. 

As a rule, every aniline dye has one or more standard 
solutions which are used largely to the exclusion of others, 
for the reason that, being required for certain purposes, they 
are kept in stock. As they are thus always at hand, they 



246 PATHOLOGICAL TECHNIQUE. 

are used where simple solutions might be used. For in- 
stance, Loffler's methylene-blue solution is often used, be- 
cause ready and convenient, when a simple aqueous solution 
would do as well. 

In the following pages we have arranged under each dye 
the solutions of it most in use : 

Methylene-blue. 

1. Saturated solution in 95 per cent, or absolute alcohol. 
A stock solution to be used in making other solutions. It 
can be used as a stain by adding 1 part to 9 parts of water. 

2. Aqueous solutions of various strengths are often used, 
and can be made up as needed. 

3. Loffler's Methylene-blue Solution. — 

Saturated alcoholic solution of methylene-blue, 30 c.c. ; 
Solution of caustic potash in water, 1 : 10,000, 100 " 

This is one of the most useful of the aniline staining solu- 
tions, and will keep for a long time without losing much in 
staining power. 

4. K'uhne's Methylene-blue Solution. — 

Saturated alcoholic solution of methylene-blue, 10; 
5 per cent, carbolic-acid water, 90. 

This is a stronger staining solution than Loffler's, but the 
resulting stain does not seem so sharp and clear. 

5. Gabbefs Methylene-blue Solution. — 
Methylene-blue, 2 ; 
Sulphuric acid, 25 ; 
Water, 75. 

It is used as a decolorizer and contrast-stain for tubercle 
bacilli. 

6. Unncts Alkaline Methylene-blue Solution. — The strongly 
alkaline solution of methylene-blue recommended by Unna 
for staining plasma-cells has been found extremely valuable 
as a general stain in connection with eosin, which should be 
used first. The solution should be diluted 1 : 10, or even 
more, for staining : 



HISTOLOGICAL METHODS. 247 

Methylene-blue, 1 ; 

Carbonate of potassium, 1 ; 

Water, 1 00. 

7. Unnds Polychrome Methylene-blue Solution. — The poly- 
chrome methylene-blue solution, much used by Unna in 
various staining methods, is an old alkaline solution of 
methylene-blue, of which the above is the original formula, 
in which, in consequence of oxidation, methyl-violet and 
methylene-red have formed. Months are required for the 
process of oxidation to take place. The ripened solution 
may be obtained from Grubler. 

8. Sahli's Borax Methylene-blue Solution. — 
Saturated aqueous solution of methylene-blue, 24 ; 
5 per cent, solution of borax, 16; 
Water, 40. 

Mix, let stand a day, and filter. 

Fuchsin. 

1. Saturated alcoholic solution to be kept in stock. 

2. Ziehl-Neelson 's Carbol-fucJisin. — 

Saturated alcoholic solution of fuchsin, 10 c.c. ; 

5 per cent, carbolic-acid water, 90 " 

This solution is very powerful, stains quickly, keeps well, 
and can be employed for a variety of purposes. 

3. Aniline-fuchsin. — 

Saturated alcoholic solution of fuchsin, 16 c.c.; 

Aniline-water, 84 

Gentian-violet. 

1. Saturated alcoholic solution to be kept in stock. 

2. EhrlicJis Aniline-gentian-violet. — 

Saturated alcoholic solution of gentian-violet, 16 c.c.; 
Aniline-water, 84 " 

During the first few hours after the solution is made con- 
siderable precipitation takes place, so that it is best not to 



248 PATHOLOGICAL TECHNIQUE. 

use it for twenty-four hours. After about ten days it begins 
to lose its staining power. 

Zenker recommends a solution without alcohol : Dissolve 
the gentian-violet directly in the aniline-water. The color is 
said to be less easily removed from tissues when this solu- 
tion is used. 

3. Stirling's Solution of Gentian-violet. — 

Gentian-violet, 5 grams ; 

Alcohol, 10 c.c. ; 
Aniline, 2 " 

Water, 88 " 

This solution is said to keep remarkably well. 

4. Carbol-gentian Violet. — 

Saturated alcoholic solution of gentian-violet, 10 c.c. ; 
5 per cent, carbolic-acid water, 90 " 

Safranin. — Two of the many preparations by this name 
have been found especially useful : 

1. Safranin O soluble in water. 

2. Safranin soluble in alcohol. 

The three following solutions of safranin can be thoroughly 
recommended : 

1. Saturated aqueous solution of "safranin O soluble in 
water " (to be made with the aid of heat). 

2. A mixture of equal parts of — 

A saturated aqueous solution of " safranin O soluble 

in water." 
A saturated alcoholic solution of " safranin soluble in 

alcohol." 

3. Babes' Aniline Safranin. — 

2 per cent, aniline-water, 100; 

" Safranin O soluble in water," in excess. 

Saturate the solution by heating it in a flask set in hot water 
to 60-80 C. ; filter. 

This solution is extremely powerful, stains almost in- 
stantly, and will keep about two months. 

Methyl-violet. — 1. Aqueous solutions of various strengths, 



HISTOLOGICAL METHODS. 249 

\ to 2 per cent., keep well and are used for staining nuclei, 
bacteria, and amyloid. 

2. Methyl-violet can be used instead of gentian-violet in 
Ehrlich's solution. 

3. For staining neuroglia-fibers Weigert employs a satu- 
rated solution made with the aid of heat in 70-80 per cent, 
alcohol. 

Bismarck Brown. — The most common solutions are the 
following : 

1. A 1 per cent, aqueous solution. 

2. A saturated aqueous solution made by boiling (3-4 per 
cent.). 

3. A saturated solution in 40 per cent, alcohol (2-2-J- per 
cent). 

Unlike other aniline colors, Bismarck brown will keep in 
glycerin mounts and can be fixed in nuclei by acid alcohol. 
The stain is not used so much as formerly, except for photo- 
graphic purposes. Other basic stains less frequently used, 
and then generally in aqueous solutions, are dahlia, methyl- 
green, iodin-green, and thionin. 

Diffuse Stains. — I . Eosin is sold in two forms — as " eosin 
soluble in water," and as " eosin soluble in alcohol." The 
first is to be preferred, because a greater degree of differen- 
tiation in stain can be obtained with it. Keep on hand a 
saturated aqueous solution and dilute with water as needed. 
The strength of solution to be used varies somewhat with 
the tissue and the reagent in which it has been fixed, but 
generally lies between y 1 ^ and \ per cent, when the eosin is 
used after a hematoxylin stain. When it is employed before 
an aniline dye such as methylene-blue, a 5 per cent, or even 
a saturated solution should be taken. 

2. Picric Acid. — Saturated alcoholic and aqueous solu- 
tions should be kept in stock, to be diluted as needed. 

3. Van Gieson's Solution of Picric Acid and Acid Fuch- 
sin. — This valuable solution was originally made by adding 
to a saturated aqueous solution of picric acid enough of a 
saturated aqueous solution of acid fuchsin to give to the fluid 
a deep garnet-red color. Freeborn has recently given more 



250 PATHOLOGICAL TECHNIQUE. 

precise directions for making up the solution according to 
the purpose for which it is to be used. 

For Connective Tissue. — (See page 300). 
1 per cent, aqueous solution of acid fuchsin, 5 c.c. ; 
Saturated aqueous solution of picric acid, 100 " 

For the Nervous System. — (See page 306). 

1 per cent aqueous solution of acid fuchsin, 1 5 c.c. ; 

Saturated aqueous solution of picric acid, 50 " 

Water, 50 " 

Picro-nigrosin (Martinotti). — Dissolve picric acid and 
nigrosin to saturation in 70 per cent, alcohol. 

Combination Stains. — Biondi-Heidenhain Staining* 
Solution. — 

Saturated aqueous solution of orange G, 100; 

Saturated aqueous solution of acid fuchsin, 20 ; 

Saturated aqueous solution of methyl-green, 50. 

Make up the separate solutions and let them stand for seve- 
ral days with excess of coloring matter (shaking the bottles 
occasionally) until they are saturated. Then mix the solu- 
tions. For staining dilute the combined solution with water 
1 : 100. 

The following tests are used for finding out if the proper 
combination has been obtained: The addition of acetic acid 
should make the solution redder ; a drop of the solution on 
filter-paper should make a blue spot with green in the center 
and orange at the periphery. If a red zone appears outside 
of the orange, then too much acid fuchsin is present. 

Pianese's Staining Solutions and Staining Meth- 
ods. — The following stains, devised by Pianese, are recom- 
mended by him particularly for the study of cancer, but will 
be found useful in many lines of histological investigation. 
The first two were used by him for tissues hardened in cor- 
rosive sublimate or in Zenker's fluid ; the others, only after 
his special fixative (given on page 225). The methods are 
intended for paraffin sections : 



HISTOLOGICAL METHODS. 2$ I 

1. Carmine and Picro-nigrosin. — i. Stain in neutral or 

lithium carmine. 

2. Decolorize in acid alcohol. 

3. Wash in water. 

4. Absolute alcohol. 

5. Anilfne-gentian-violet, ten minutes. 

6. Iodin solution, two to three minutes. 

7. Absolute alcohol, so long as any color is discharged. 

8. Saturated aqueous solution of picric acid and of nigro- 
sin, five minutes. 

9. Decolorize in a 1 per cent, alcoholic solution of oxalic 
acid. 

10. Water, several minutes. 

11. Absolute alcohol. 

12. Oil of bergamot. 

13. Balsam. 

Nuclei, red ; cell-protoplasm, light olive-green ; connec- 
tive tissue, dark olive-green ; elastic fibers, bluish ; bacteria 
and blastomycetes, violet. 

II. Methylene-blue and Eosin in Borax Solution. — 
Keep three solutions on hand : 

(a) Saturated solution of methylene-blue in a saturated 
aqueous solution of borax. 

(b) -J per cent, solution of " bluish eosin " in 70 per cent, 
alcohol. 

(c) Saturated aqueous solution of borax. 

For use mix together 2 parts of the filtered solution a, 1 
of b, and 2 of c. The different steps of the staining pro- 
cess are as follows : 

1. Absolute alcohol. 

2. Staining solution, ten to twenty minutes. 

3. Decolorize in a 1 per cent, solution of acetic acid. 

4. Wash in water. 

5. Absolute alcohol. 

6. Xylol. 

7. Xylol balsam. 

Nuclei, blue ; red blood-globules, cell-protoplasm, granules 
of eosinophiles, connective tissue, etc., rose-red. 



252 PATHOLOGICAL TECHNIQUE. 

III. a. Malachite-green, Acid Fuchsin, and Nigrosin. — 
Malachite-green, I . gram ; 

Acid fuchsin, .4 " 

Nigrosin, .1 

Water, 50 c.c. ; 

Alcohol saturated with acetate of copper, 50 " 

1. Absolute alcohol. 

2. Stain in 20 drops of above solution diluted with 10 c.c. 
of distilled water for twenty-four hours. 

3. Decolorize in a \ per cent, aqueous solution of oxalic 
acid. 

4. Wash in water. 

5. Absolute alcohol. 

6. Xylol balsam. 

Resting nuclei, light red; protoplasm, reddish yellow. In 
the karyokinetic figures, nuclein green ; fibrillar of the achro- 
matic spindle and of the mitoma, bright red; centrosome 
and polar bodies, red ; the rest of the cell-body, a reddish- 
yellow color. 

III. b. Malachite-green, Acid Fuchsin, and Martius 
Yellow. — 

Malachite-green, .5 gram ; 

Acid fuchsin, .1 " 

Martius yellow, .01 " 

Distilled water, 150 c.c; 

Alcohol, 96 per cent, 50 " 

1. Stain in the solution without diluting, half an hour. 

2. Absolute alcohol. 

3. Xylol. 

4. Xylol balsam. 

Nuclei of resting and dividing cells, green ; cell-protoplasm, 
connective tissue, etc., rose-colored ; " cancer-bodies," mainly 
red, but in masses of them some are red and some green. 

IV. Acid Fuchsin and Picro-nigrosin. — 
Saturated alcoholic solution of acid fuchsin, 6 drops ; 
Martinotti's picro-nigrosin, 8 " 
Distilled water, 10 c.c. 



HISTOLOGICAL METHODS. 253 

1. 70 per cent alcohol. 

2. Stain in the solution six hours. 

3. Decolorize in dilute acetic acid. 

4. Absolute alcohol. 

5. Xylol. 

6. Xylol balsam. 

Resting nuclei, red ; nuclein of karyokinetic figures, yellow : 
cell-protoplasm, dark olive-green ; " cancer-bodies," mainly 
olive-gray, but some or portions of them may be ruby-red. 

V. Light Green (Lichtgriin) and Hematoxylin. — 
Ehrlich's acid hematoxylin, 1 5 c.c. 
Saturated solution of Lichtgriin in 70 per cent. 

alcohol, 5 " 

Distilled water, 15 " 

1. Distilled water. 

2. Stain in above mixture half an hour. 

3. Wash thoroughly in several waters. 

4. Alcohol. 

5. Oil of bergamot. 

6. Balsam. 

Nuclei, green ; " cancer-bodies " take the hematoxylin stain. 

VI. Acid Fuchsin and Hematoxylin. — 

Ehrlich's acid hematoxylin, 15 c.c. 

I per cent, solution of acid fuchsin in 70 per 

cent, alcohol, _ 15 " 

Distilled water, 1 5 " 

Stain as in V. 

Nuclei, red ; protoplasm, brick-red ; " cancer-bodies " take 
the hematoxylin stain. 

Orcein, a vegetable dye obtained from certain tinctorial 
lichens, is used mainly for staining elastic fibers. It is 
soluble in alcohol, and is employed either in a neutral or 
acid (HC1) alcoholic solution. 

Iodin is the oldest of the histological stains, but is now 
but little used for that purpose. 

The tincture of iodin, a saturated solution in alcohol, is 



254 PATHOLOGICAL TECHNIQUE. 

used for getting rid of the precipitate of mercury formed in 
tissues fixed in corrosive sublimate or in Zenker's fluid ; a 
small amount of the tincture is added to the alcohol in which 
the tissue is preserved (see page 223). 

1/U.goPs solution, a solution of iodin in water containing 
iodid of potash, is of varying strength. Iodin in this form 
is much used as a test for starch, amyloid, glycogen, and 
corpora amylacea. In Gram's stain and its modifications iodin 
produces some chemical change in the coloring material em- 
ployed, in consequence of which, when appropriate decolor- 
izers are used, the stain remains fast in certain structures, 
while from others it is easily entirely extracted. 

The strength originally employed by Gram for his stain- 
ing method was — 



Iodin, 


1 gram; 


Iodid of potash, 


2 grams ; 


Water, 


300 c.c. 



Weigert in his modification of this method employed a 
stronger solution : 



Iodin, 


1 gram ; 


Iodid of potash, 


2 grams ; 


Water, 


IOO c.c. 



Recently he has recommended the following strength both 
for fibrin and for neuroglia-fibers : 

Iodid of potash, c grams 1 , .,, . ;. 

r ' J fe > saturated with iodin. 

Water, 100 c.c. J 

The only difference in the action of the various solutions 
probably is that the strong solution acts practically instan- 
taneously, while the weaker solutions require some little time. 

Acid Alcohol (Orttis Discharging Fluid). — 

Hydrochloric acid, 1 c.c. ; 

70 per cent, alcohol, 99 " 

Aniline Water {Aniline-oil Water). —Shake together 5 



HISTOLOGICAL METHODS. 255 

parts of aniline with 95 parts of water, and filter the re- 
sulting milky fluid. It should come through perfectly clear. 

Carbolic-acid water is made in like manner by shaking 
together 5 c.c. of melted carbolic-acid crystals and 95 c.c. 
of water. The solution should be filtered. 

Mayers glycerin-albumin mixture for attaching 
paraffin sections to slides is composed of equal parts of the 
white of egg and of glycerin. The mixture should be thor- 
oughly beaten and then filtered, or after standing for some 
time can be decanted. Add a little camphor or carbolic acid 
to prevent decomposition. Egg-albumin is dissolved by 
acids and alkalies, so that when such reagents are to be 
used the sections are best attached to the slide by some 
other substance. For this purpose Schdllibaitm s solution, 
of celloidin 1 part in 3 or 4 parts of oil of cloves, is often 
useful. Cover the slide with a thin layer of the solution. 
Arrange the sections in order on the slide and place it in 
the thermostat at 54 to 60 ° C. for several hours, or heat 
for a few seconds to half a minute over the flame until the 
oil of cloves runs together in drops. After cooling, remove 
the paraffin with xylol, pass through origanum oil to 95 per 
cent, alcohol, and proceed as with other paraffin sections. 

Clearing Reagents. — The object of clearing reagents 
is to render certain tissue-elements more prominent than 
others. This result may be brought about by dilute acetic 
acid (2-5 : 100), which swells up the ground substance, so 
that nuclei, elastic fibers, fat, myelin, and micro-organisms 
are more distinct, or by alkalies, which destroy the cells and 
ground substance and leave only elastic fibers and bacteria 
but little changed. This method is used almost wholly for 
fresh tissues. 

The same result is more commonly obtained by soaking 
the tissues in substances which by reason of their high index 
of refraction render the tissues more or less transparent. 
Any structure which it is desirable to study is usually pre- 
viously stained and thus easily rendered prominent. This 
second method is most applicable to hardened tissues. 

For soaking and clearing the tissues a variety of reagents 



256 PATHOLOGICAL TECHNIQUE. 

of different chemical properties are used. Glycerin and 
acetate of potash are not so much employed as formerly, 
because balsam mounts are more generally preferred. Of 
the other reagents (ethereal oils and coal-tar products), the 
the choice depends mainly on two factors — the kind of stain 
which has been employed, and the substance in which the 
sections have been imbedded. Many of the clearing re- 
agents either dissolve celloidin or will not clear it from 95 
per cent, alcohol, and nearly all of them will extract aniline 
colors more or less rapidly. 

Most of the clearing reagents can be used after hema- 
toxylin and carmine stains. For celloidin or paraffin sections 
stained by either of them oleum origani cretici, oil of ber- 
gamot, or the mixture of the oils of cloves and thyme is 
recommended in the order given. 

After aniline stains the best clearing reagent is xylol, 
which, however, clears only from absolute alcohol. It is to 
be used, therefore, for unimbedded sections and for paraffin 
sections dehydrated in absolute alcohol. 

The most difficult problem in clearing is offered by cel- 
loidin sections stained with aniline dyes. It is, perhaps, best 
solved by clearing and dehydrating in oleum origani cretici 
or in oil of bergamot after 95 per cent, alcohol, and then 
washing out the oil with several changes of xylol before 
placing in balsam. 

For certain dyes other clearing reagents may be used, as 
aniline after gentian-violet or fuchsin, but for methylene- 
blue, which seems to be one of the most sensitive of the 
aniline dyes, the above method is particularly recommended. 
Occasionally the decolorizing effect of certain of the clearing 
reagents is purposely made use of (see oil of cloves, page 
279). 

Oleum Origani Cretici. — Light brown in color; clears 
readily from 95 per cent, alcohol without dissolving cel- 
loidin ; affects aniline colors slowly. Ordinary origanum 
oil is impure oil of thyme and should not be used. 

Oil of Bergamot. — Light green in color ; clears quickly 
from 95 per cent, alcohol ; does not dissolve celloidin, but 



HISTOLOGICAL METHODS. 2$? 

after repeated use of the same lot of oil it will sometimes 
soften it a little. Affects aniline colors slowly, with the ex- 
ception of eosin, which it extracts very quickly. 

Oil of Cloves. — Straw-colored ; clears quickly from 95 per 
cent, alcohol ; dissolves celloidin ; extracts aniline colors, 
especially methylene-blue. 

Oil of Thyme. — Colorless ; clears readily from 95 per 
cent, alcohol ; makes sections brittle ; does not dissolve cel- 
loidin ; affects aniline colors. 

Oil of Lavender. — Clears celloidin sections readily from 
95 per cent, alcohol. 

Oil of Cedar- wood. — Pale straw-color ; clears from 95 per 
cent, alcohol, but, unfortunately, clears celloidin sections very 
slowly ; does not affect aniline colors. 

Aniline (Aniline Oil). — Colorless when perfectly pure and 
fresh, but soon oxidizes and turns brown ; does not dissolve 
celloidin ; clears readily from 70 per cent, alcohol ; will clear 
from water by Weigert's method; extracts aniline colors 
slowly. 

Xylol. — Colorless ; does not dissolve celloidin ; will clear 
from absolute alcohol only ; does not affect aniline colors ; 
shrinks sections considerably. 

Dunham's Mixture of the Oils of Cloves and Thyme. — 
Excellent for sections stained in hematoxylin or carmine. 
Not nearly so expensive as pure origanum or bergamot oil. 

Oil of cloves, I part; 

Oil of thyme, 4 parts. 

Filter if cloudy ; clears celloidin sections readily from 95 per 
cent, alcohol without dissolving the celloidin. 

Weigert's Mixture of Carbolic Acid and Xylol. — 
Carbolic-acid crystals, 1 part ; 

Xylol, 3 parts. 

Recommended for clearing thick sections of the central 
nervous system after carmine and hematoxylin stains only. 
The next mixture is more used now-a-days. 
17 



258 PATHOLOGICAL TECHNIQUE. 

Weigert's Mixture of Aniline and Xylol. — 

Aniline, 2 parts ; 

Xylol, 1 part. 

Mounting Reagents. — The most generally used reagent 
for permanent mounts is Canada balsam. Damar and colo- 
phonium are only exceptionally preferred. 

Canada balsam occurs in commerce as a very thick, tena- 
cious, pale, straw-colored fluid. It should be evaporated 
over a water-bath to drive off all volatile substances, which 
might affect aniline colors, until it becomes solid and brittle 
on cooling. Dissolve it then in xylol, which does not affect 
aniline colors, to a rather thin, syrupy consistency. In this 
condition it is often called xylol balsam. 

Canada balsam has a high index of refraction, so that tis- 
sues mounted in it become very transparent, and only those 
parts are visible which are stained. Other solvents of Canada 
balsam, such as chloroform and benzine, may be used, but 
cannot be recommended for sections stained with aniline 
colors. 

Damar has a lower index of refraction than Canada bal- 
sam ; is soluble in xylol, chloroform, etc. ; dries slowly, and 
is generally recommended for Golgi preparations. 

Colophonium dissolved in benzine is employed by Nissl 
for mounting stained preparations of ganglion-cells. 



METALLIC STAINS OR IMPREGNATIONS. 

Experimental investigation has shown that certain metals 
can be used for staining certain tissue-elements, either be- 
cause they are directly reduced from solutions of appropriate 
salts or because they are taken up and retained by certain 
tissue-elements, which are rendered prominent when the 
metallic salt is reduced later. The most valuable metals for 
this purpose are silver, gold, and osmium. 

Silver is used, generally in the form of silver nitrate, to 
stain of a brown or dark-brown color the cement substance 



HISTOLOGICAL METHODS. 259 

between epithelial and endothelial cells and the ground sub- 
stance of connective tissue. The method finds its chief use 
in pathology in demonstrating the endothelial covering of a 
doubtful surface, in outlining the endothelial cells of patho- 
logically altered blood- and lymph-vessels, and in staining 
the ground substance of the connective tissue of the cornea 
when that organ is used experimentally for the study of in- 
flammation. In combination with certain other salts, espe- 
cially bichromate of potassium, nitrate of silver is much em- 
ployed in the Golgi methods to stain ganglion-cells and their 
processes in the central nervous system. 

The difficulty of the silver method lies in the fact that the 
salt forms with albuminous fluids granular and thread-like 
coagula which can easily give rise to false pictures. For 
this reason the method is limited almost entirely to natural 
surfaces, which should be washed off with water or a 2 
per cent, solution of nitrate of sodium before the silver solu- 
tion is applied. It is generally advisable to use the nitrate 
of silver in a very dilute solution, 1 : 250 or 500. The solu- 
tion is allowed to act on the surface for about a minute, and 
is then washed off with water. The tissue is next exposed 
in water to the action either of sunlight or of diffuse light. 
The outlines of the cells soon appear as dark lines, brown to 
black in color. The tissue to be stained should be kept 
stretched, because a precipitation of the silver occurs 
wherever there is a fold in the surface. Although nitrate 
of silver penetrates but a slight distance, it is possible to 
stain the outlines of the endothelial cells of the lymphatics 
and blood-vessels as well as the ground substance of the 
connective tissue — in a rabbit's diaphragm, for instance — by 
treating the upper or lower surface with the silver solution. 
The thoracic organs should be removed, and then the upper 
surface of the tendinous portion of the diaphragm left in 
situ is exposed to the action of the silver salt in the manner 
already described. 

The outlines of the endothelial cells of blood-vessels are 
usually stained by injections of the silver salt through an 
artery. In the same way the limits of the epithelial cells 



26o PATHOLOGICAL TECHNIQUE. 

of the alveoli of the lung can be stained by injections through 
a bronchus. 

Although generally employed in solution, nitrate of silver 
is sometimes used in the solid form, and for the cornea this 
method is preferable. Chloroform the animal, preferably a 
rabbit, deeply ; rub the cornea with a stick of nitrate of 
silver hard enough to remove the surface epithelium. Allow 
the salt to act about ten minutes, then kill the animal, re- 
move the eye, cut out the cornea, wash it, and expose to 
diffuse daylight for half an hour. It is then placed in a 
mixture of glycerin and water, 30 parts to 70, very slightly 
acidulated with acetic acid (about y 1 ^ per cent.) for twenty- 
four hours, so as slightly to swell and to soften the tissues. 
Sections of the cornea are best made with the freezing 
microtome. Incise the periphery a little at four points 
equally distant from each other, so that the cornea will lie 
flat. A direct stain with alum-hematoxylin gives by all odds 
the best results. The sections may be mounted in glycerin 
or balsam. The latter method is perhaps the better. De- 
hydrate the sections in 50 per cent., then in 70 per cent., 
alcohol, clear in aniline oil, wash with xylol, and imbed in 
balsam. This method avoids the shrinkage which is caused 
by using strong alcohol. 

Gold, in the form of the simple or double chlorid, is em- 
ployed to stain the protoplasm of cells of connective tissue, 
and more particularly the axis-cylinders of nerve-fibers and 
their terminal processes. Like nitrate of silver, it acts as a fix- 
ing and hardening reagent as well as a stain. Unfortunately, 
it penetrates tissues but a very slight distance, and, so far as 
staining is concerned, is inconstant in action. Its chief use 
in pathology is in connection with experimental work on the 
cornea and in regeneration. The conditions under which 
the reduction of the gold salt takes place are not exactly 
understood, but both penetration and reduction are aided 
by the action of organic acids, such as formic, citric, and 
tartaric acids, on the tissues both before and after the treat- 
ment with the gold salt. Of the many methods proposed, 
the following are recommended : 






HISTOLOGICAL METHODS. 26 1 

Lowit's Formic-acid Method. — 1. Place very small bits 
of fresh tissue in a mixture of formic acid 1 part, and water 

1 to 2 parts, until they become transparent (a few seconds 
to several minutes). 

2. Transfer to chlorid of gold, 1 to 1.5 parts to 100 of 
water, for fifteen minutes. 

3. Formic acid, 1 part to water 3 parts, for twenty-four 
hours. 

4. Concentrated formic acid twenty-four hours. Preserve 
in glycerin or balsam. 

All the steps except the first should be performed in the 
dark. 

Ranvier's Formic-acid Method. — 1. Boil together 8 c.c. 
of a 1 per cent, solution of chlorid of gold and 2 c.c. of 
formic acid. When the solution is cold place very small 
bits of tissue in it for one hour, in the dark. 

2. Wash quickly in water. 

3. Expose to diffuse light in a mixture of formic acid 10 
c.c. and water 40 c.c. Reduction takes place slowly (twenty- 
four to forty-eight hours). 

4. Harden in 70 per cent., then 90 per cent., alcohol in 
the dark. 

Ostnic Acid (perosmic acid, osmium tetroxid) is used as 
a fixing reagent and for staining fat and myelin, by which it 
is reduced. As osmic acid is quickly reduced by organic 
substances, care must be taken in making up the solution. 
Remove the label from the sealed tube in which the acid 
comes, and place the tube, after cracking off one end, in a 
glass-stoppered bottle containing enough water to make a 

2 per cent, solution. If desired, the tube can be broken 
after it is in the bottle by violent shaking. It should be 
borne in mind that osmic acid is very-irritating to the bron- 
chial mucous membrane. 

In a I or 2 per cent, solution osmic acid is used to stain fat 
in teased preparations or frozen sections of fresh tissues. In 
Marchi's method it is used to stain fat in tissues which have 
been hardened for some time in Muller's fluid. As a fixing 
reagent it is usually combined with other reagents, as in Flem- 



262 PATHOLOGICAL TECHNIQUE. 

ming's solution, both for its property as a fixative and for the 
purpose of staining any fat present. 



STAINING METHODS. 

The purpose of staining is to render prominent the differ- 
ent tissue-elements, so that they may be readily recognized 
and studied. The constant tendency now-a-days is toward 
selective or differential staining methods, by which but one 
tissue-element will be colored to the exclusion of all others, 
or at least of any element that might be confused with it 
morphologically. These selective stains, which really are 
micro-chemical color reactions, enable us to differentiate 
from each other with ease and accuracy cellular and inter- 
cellular elements, or pathological products which otherwise 
look alike. 

The list given on page 263 does not pretend to be either 
complete or perfect in arrangement, but will give some idea of 
the various elements which we wish to stain. Those for 
which we now possess more or less perfect differential stains 
are printed in italics. 

The simplest selective stain is, of course, that for nuclei, 
and it can be obtained with a great variety of staining re- 
agents. The most difficult element to stain differentially, 
although it can be done under certain conditions with a fair 
amount of success, is probably the axis-cylinder and its ter- 
minal processes. 

Tissue-elements and pathological products differ from 
each other, not only in form and consistency, but also in 
chemical properties. While perfect preservation of form is 
sufficient to distinguish certain cells or elements from each 
other — as, for instance, polynuclear leucocytes from lymph- 
oid cells — differentiation based on micro-chemical tests is 
always to be preferred when possible. A few of the tests 
employed are colorless, like the precipitation of mucin by 
acetic acid. Certain tests, like the methylene-blue or gold 
stain for axis-cylinders, can be applied to fresh tissues only. 



HISTOLOGICAL METHODS. 



263 



Cell. 



Nucleus. 



Protoplasm. 



Cuticle. 



f Nucleolus. 
Resting nucleus. 
Linin. 

/ I. Do not stain by Gram. 
Bacteria. \ 2 - Stain by Gram. 

v 3. Stain by tubercle-bacillus method. 
Nucleus of ameba colt. 
c Centrosome and polar bodies. 
Alastzellen. 
Plasma-cell of Unna. 

{Five kinds of gran- 
ules described by 
Ehrlich. 
NissTs granules in ganglion-cells. 
Dendritic processes of ganglion-cells. 
Axis-cylinder attd terminal processes. 
Contractile elements of striated muscle-fiber. 
Red blood-globules. 
I Cilia of bacteria. 
Certain dots in ependymal cells. 
So-called cilia in certain renal cells. 
Bile- cap ilia ries . 



Granules. \ 



Intercellular 
substances. 



f Cement substance of endothelial cells. 
Ground substance of connective tissue. 
Connective-tissue fibrillce. 
Myxomatous tissue ; mucin. 
Elastic fibers. 

Intercellular substances of cartilage. 
Ground substance of bone. 
Myelin. 

Neuroglia-fibers. 
Clubs of actinomyces. 
Capsules of bacteria. 



Pathological 
products. 



j Hyaline substances. 



Fat. 

Hemosiderin. 
j Hematoidin. 
I Hemoglobin. 



\ Fibrin. 

Mucin. 

Amyloid. 

Glycogen. 

Hyalin. 

Colloid. 

Ke r at hyalin. 
y Eleadin. 



264 PATHOLOGICAL TECHNIQUE. 

Others, like the various amyloid reactions, can be obtained 
with fresh or hardened tissues. Most of the micro-chemical 
reactions, however, can be employed only with tissues which 
have been properly preserved. It is exceedingly important, 
therefore, that a tissue-element be so fixed and hardened that 
its peculiar chemical properties be preserved intact, otherwise 
a differential stain for it is impossible. Each tissue-element 
is a law unto itself. For example, the peculiar chemical 
properties of red blood-globules depend on the presence in 
them of hemoglobin. As a differential stain of the red 
blood-globules depends on fixing this substance in them, it 
is necessary to find out the chemical properties of hemo- 
globin, such as the fact that it is soluble in water or dilute 
alcohol, but not in salt solution, and that it is fixed in the 
red blood-globules by heat, absolute alcohol and ether equal 
parts, corrosive sublimate, formaldehyde, bichromate of po- 
tassium, etc. 

While differential stains depend in part on the chemical 
properties of the tissue-elements, they also depend to a cer- 
tain extent on the chemical properties of the staining re- 
agents and the decolorizers used. 

Some of the tissue-elements can be stained differentially in 
a number of ways, sometimes after one fixing agent, some- 
times after another. The simplest differential stains are those 
where certain tissue-elements stain directly in a given solu- 
tion after they have been properly fixed. Good examples 
are — Ehrlich's triple stain for certain protoplasmic granules 
in leucocytes, and the direct stain for elastic fibers with an 
acid alcoholic solution of orcein. 

Other differential stains depend on the property of certain 
elements to hold colors they have once taken up when 
treated with decolorizers. The best example of this is the 
tubercle bacillus, which holds certain stains through various 
acids, or aniline hydrochlorate, followed by alcohol, and, if 
necessary, by a contrast-stain. 

Still another varied group of elements (certain bacteria, 
fibrin, neuroglia-fibers, etc.) depends for a differential stain in 
part on changes produced in gentian- or methyl-violet by 



HISTOLOGICAL METHODS. 265 

iodin, in part on the decolorizer employed for extracting the 
coloring reagent. 

Although the steps of the various staining methods differ 
considerably, they may be roughly arranged in the following 
order : 

1. Staining. 

2. Differentiating. 

3. Decolorizing. 

4. Dehydrating. 

5. Clearing. 

6. Mounting. 

Very often two or more of the steps are combined in one, 
as when aniline oil is used for decolorizing, dehydrating, and 
clearing sections stained for certain bacteria. Sometimes the 
staining process occupies more than one step, as in Weigert's 
myelin-sheath stain. In alum-hematoxylin the differentiating 
reagent, the excess of alum, is combined with the stain ; in 
Gram's method the differentiating reagent, iodin, forms a step 
by itself. 

NUCLEAR STAINS. 

For general histological work few stains are more valua- 
ble or can be more highly recommended than alum-hema- 
toxylin, either alone or in contrast with eosin. Prop- 
erly made and used, the solution stains the nuclei sharply 
and of varying degrees of intensity, depending on the cha- 
racter of the cells. Besides the nuclei, however, it stains 
other tissue-elements in delicate shades of blue, so that they 
are readily visible, and thus more or less differentiated from 
those structures which fail to stain. 

Of the carmine stains, lithium carmine, followed by picric 
acid, will be found the most brilliant, generally useful, and 
permanent. 

Safranin gives, perhaps, the most permanent stain of any 
of the basic aniline dyes, and confines itself very sharply to 
the nuclei. It is much used after certain fixing reagents, such 
as Flemming's and Hermann's solutions. Eosin, followed by 
methylene-blue, gives beautiful results, especially when 



266 PATHOLOGICAL TECHNIQUE. 

Unna's alkaline solution of methylene-blue is used. The 
advantages of this solution are that it stains readily tissues 
hardened in Zenker's fluid and brings out nuclei and nuclear 
figures with great sharpness, while at the same time it stains 
the protoplasm of certain cells so that they are easily dis- 
tinguished from other cells. The Heidenhain-Biondi triple 
stain is useful after fixation in corrosive sublimate, but can- 
not be employed with celloidin sections, so that its field is 
limited. The other aniline dyes are used on occasion or for 
some definite purpose, but not so generally as those men- 
tioned above. 

Alum-hematoxylin Stains. — Most alum-hematoxylin 
solutions will over-stain if the sections are left too long in 
them. The proper time required depends on the fixing re- 
agent used and on the degree of ripeness of the staining 
solution. It is therefore advisable to wash a section in water 
occasionally and decide from the color it has acquired if it 
be sufficiently stained, or to mount it in water on a slide and 
examine with the low power of the microscope. 

The best results are obtained with alum-hematoxylin solu- 
tions by staining sections just deeply enough, washing them 
thoroughly in several changes of water, and leaving them in 
a large dish of water over night. This thorough washing is 
done to rid the tissues of every trace of alum or of acid, so 
that the color will become a clear blue and will keep in- 
definitely. 

Many microscopists prefer to stain deeply and diffusely in 
an old, quickly-staining alum-hematoxylin solution, and then 
to employ a decolorizer. The agents most used for the pur- 
pose are alum (i per cent, aqueous solution for one to two 
hours), hydrochloric acid (^ to \ per cent, aqueous solution, 
or even the ordinary acid alcohol), and acetic acid (i to 3 per 
cent, solution) for a few seconds only. After being suf- 
ficiently decolorized the sections must be thoroughly washed 
in water, preferably for a number of hours, otherwise the 
stain will fade. The objection to this method is that a pure 
nuclear stain only is obtained, because the acid removes the 
color completely from all the rest of the tissue. Under cer- 



HISTOLOGICAL METHODS. 267 

tain circumstances, as when hematoxylin is used as a con- 
trast-stain to fuchsin in staining for tubercle bacilli, such a 
sharp limitation to the nuclei is desirable. 

Alum-hematoxylin stains well and quickly tissues hard- 
ened in alcohol, in corrosive sublimate, and in picric acid. 
It stains much more slowly tissues hardened in solutions 
containing chrome salts, such as Zenker's and Muller's 
fluids. 

For counter-staining eosin will usually be found to give 
the most beautiful contrast, although picric acid, Van 
Gieson's mixture, and neutral carmine are often of service. 

A good alum-hematoxylin solution should have a bluish 
or purplish color, and should stain celloidin very faintly or 
not at all. 

Aqueous Alum-hematoxylin; Delafield's Hema- 
toxylin ; Ehrlich's Acid Hematoxylin (see pages 241 
and 242). 

1. Stain in one of the above solutions two, five, or thirty 
minutes, or sometimes even longer. 

2. Wash in several changes of water, and then leave sec- 
tions, if possible, for several hours or over night in a large 
dish of water. 

3. Contrast-stain, usually an aqueous solution of eosin, 
Yq to J- per cent, for one to five minutes. 

4. Alcohol, 95 per cent., two or three changes to dehydrate 
and to remove excess of contrast-stain. 

5. Clear in oleum origani cretici or in Dunham's oils-of- 
cloves-and-thyme mixture. 

6. Canada balsam. 

The staining of the nuclei by Ehlrich's alum-hematoxylin 
solution is not so sharp as that obtained by the simple aque- 
ous solution. 

The more customary method of using Delafield's alum- 
hematoxylin solution is to filter a few drops of it into a dish 
of water and to stain sections for a long time, even over 
night, with the very dilute solution thus obtained. It is 
sometimes advisable to use the aqueous solution in the same 
way. 



268 PATHOLOGICAL TECHNIQUE. 

Mayers Hemalum (see page 242). — 1. Stain three to 
five minutes or longer. 

2. Wash out in 1 per cent, alum solution until the stain is 
precise. 

3. Wash thoroughly in several changes of water. 

4. Alcohol, 95 per cent. 

5. Oleum origani cretici. 

6. Canada balsam. 

The staining is rather diffuse, so that it has to be washed 
out to some extent with alum-water. Mayer's acid hemalum 
is more precise, and usually does not need to be decolorized, 
so that the second step can be omitted. 

Hemalum is used for staining tissues in bulk. Twenty- 
four hours are required for large pieces. 

Heidenhain's Hematoxylin Stain. — 1. Stain twenty- 
four to forty-eight hours in a simple \ per cent, aqueous 
solution of hematoxylin dissolved by the aid of heat. 

2. Transfer the sections directly to a J per cent, aqueous 
solution of simple chromate of potassium for twenty-four to 
forty-eight hours, changing the solution frequently until no 
more color is given off by the sections. 

3. Wash thoroughly in water. 

4. Alcohol. 

5. Oil. 

6. Canada balsam. 

Carmine Stains. — The ordinary carmine solutions give 
good nuclear stains, but of the finer details in a specimen 
they bring out much less than a direct alum-hematoxylin 
stain. They are much less used now than formerly, except 
as contrast-stains to bacteria and to fibrin in the methods of 
Gram and Weigert, for which purpose lithium carmine will 
usually give the best results. 

Alum Carmine; Alum Cochineal (see page 244). — 1. 
Water. 

2. Stain in either of the above solutions for five to twenty 
minutes. 

3. Wash thoroughly in water. 

4. Alcohol, 95 per cent. 



HISTOLOGICAL METHODS. 269 

5. Oleum origani cretici. 

6. Canada balsam. 

Over-staining does not occur. The solutions cannot be 
recommended for tissues which stain with difficulty. When 
used for staining in bulk, twenty-four to forty-eight hours are 
required. 

Lithium Carmine (see page 244). — 1. Water. 

2. Stain two to five minutes. 

3. Transfer directly to acid alcohol, one or more changes 
for several minutes or more, until the sections are well differ- 
entiated. 

4. Wash in water. 

5. Alcohol, 95 per cent. 

6. Oleum origani cretici. 

7. Canada balsam. 

This method gives an intense and permanent bright-red 
nuclear stain. Over-staining is impossible. A trace of 
picric acid added to the alcohol used for dehydration 
affords a beautiful contrast-stain. 

Aniline Dyes as Nnclear Stains. — Any of the basic 
aniline dyes may be used as nuclear stains after the following 
general method : 

1. Stain celloidin sections in a strong solution of the dye 
preferred in water or in dilute alcohol for five to thirty 
minutes. 

2. Wash in water. 

3. Dehydrate in 95 per cent, alcohol. 

4. Clear in oil of bergamot or origanum. 

5. Wash out the oil thoroughly with several changes of 
xylol. 

6. Xylol balsam. 

With paraffin sections use absolute alcohol and clear di- 
rectly in xylol. 

As a matter of fact, however, certain dyes and certain so- 
lutions are generally used in preference to the others. The 
use of aniline dyes as stains presents for solution one or two 
problems. Most of the colors are more or less affected by 
all clearing reagents except xylol. With paraffin sections 



270 PATHOLOGICAL TECHNIQUE. 

and those from which the celloidin has been removed it is 
very easy to dehydrate in absolute alcohol and to clear in 
xylol. With celloidin sections, however, this is impossible, 
because the absolute alcohol will dissolve out the celloidin, 
and this is usually not desirable. For celloidin sections it 
will therefore generally be found advisable to dehydrate in 
95 per cent, alcohol, to clear and further dehydrate in ber- 
gamot or origanum oil (the decolorizing effect of these oils 
is slight and slow), to wash out the oil with xylol, and then 
to mount in xylol balsam. 

In washing out the excess of color it is sometimes found 
advantageous to acidulate very slightly either the water or 
the first alcohol with acetic or hydrochloric acid. This pro- 
cess, if not carried too far, tends to make the nuclear stain 
sharper. 

Safranin is one of the very best nuclear-staining aniline 
dyes. Tissues may be hardened in alcohol, corrosive subli- 
mate, Flemming's, Hermann's, or Zenker's fluids. Any 
one of the solutions of safranin given on page 248 may 
be used. 

1. Stain paraffin sections two to five minutes to twenty- 
four hours according to the staining solution and fixing re- 
agent used. 

2. Wash in water. 

3. Absolute alcohol, several changes, until the section 
appears properly differentiated. 

4. Xylol. 

5. Xylol balsam. 

For celloidin sections dehydrate in 95 per cent, alcohol, 
clear in bergamot or origanum oil, and wash out in xylol. 
To render the stain more precise a few drops of acid alcohol 
are sometimes added to the first alcohol. 

Eosin and Methylene-blue. — Harden in alcohol, Zenker's 
fluid, or corrosive sublimate. 

1. Stain paraffin sections in a 5 per cent, or saturated 
aqueous solution of eosin for five to twenty minutes or 
longer. 

2. Wash in water to get rid of excess of eosin. 



HISTOLOGICAL METHODS. 27 1 

3. Stain in Unna's alkaline methylene-blue solution (see 
page 246), diluted 1-10 with water, for one half to several 
hours. 

4. Wash in water. 

5. Differentiate and dehydrate in absolute alcohol until 
the pink color returns in the section. 

6. Xylol. 

7. Xylol balsam. 

For celloidin sections use 95 per cent, alcohol, clear in 
origanum oil, and wash out with xylol. 

It is important to get a deep stain with eosin, because the 
methylene-blue washes it out to a considerable extent. The 
eosin must be used first, because methylene-blue is readily 
soluble in an aqueous solution of eosin, and therefore is 
quickly extracted if the eosin is used after it, while on the 
other hand eosin is very slightly soluble in an aqueous solu- 
tion of methylene-blue which is precipitated by any excess 
of eosin. 

Diffuse or contrast- Stains are useful to make promi- 
nent certain of the tissue-elements left uncolored by the 
nuclear stain. A greater richness of detail is obtained with 
diffuse stains if, after rather deep staining, the sections be 
washed out for some time in alcohol, because certain struc- 
tures possess a greater affinity than others for certain diffuse 
stains, and by holding them are brought out sharply. 

Of the diffuse stains, eosin, picric acid, and acid-fuchsin in 
Van Gieson's mixture are the ones most frequently em- 
ployed. 

Eosin is most frequently used as a contrast to alum-hema- 
toxylin stains, but is often serviceable with alum-cochineal, 
methylene-blue, gentian-violet, etc. It brings out particu- 
larly well red blood-globules and smooth and striated muscle- 
fibers. The strength of the solutions used after hematoxy- 
lin varies from -^ to \ per cent, according to the tissue and 
the fixative used. Zenker's preparations stain intensely in 
eosin, so that for them a very dilute solution is advisable. 
When desired as a contrast-stain to basic aniline dyes, eosin 
should be used first in a 5 per cent, or even saturated solu- 



272 PATHOLOGICAL TECHNIQUE. 

tion, because otherwise it is likely to be washed out by the 
nuclear stain. 

Picric acid is used for contrast with the carmine stains, 
more rarely with alum-hematoxylin. Striated muscle-fibers 
and cornified epithelium are rendered especially prominent 
by it. To stain with picric acid it is only necessary to add a 
few drops of a saturated aqueous solution to a dish of water, 
or of a saturated alcoholic solution to a little alcohol, and 
allow sections to remain in the solution for a few seconds. 

Van Gieson's stain (see p. 249), a mixture of picric acid 
and acid fuchsin, is excellent as a contrast-stain to alum- 
hematoxylin, especially when it is desirable to render promi- 
nent connective-tissue fibrillar or certain pathological prod- 
ucts. The nuclear stain with alum-hematoxylin must be 
rather deep, because the picric acid to some extent extracts 
or overpowers it. 

1. Stain deeply in alum-hematoxylin. 

2. Wash in water. 

3. Stain in Van Gieson's solution three to five minutes. 

4. Wash in water and dehydrate directly in 

5. Alcohol, 95 per cent. 

6. Oleum origani cretici. 

7. Canada balsam. 

Neutral Carmine (see page 245). — Neutral carmine is a 
diffuse stain, and is employed more especially for the central 
nervous system and for bone. 

Filter one or two drops of the solution into 20 c.c. of dis- 
tilled water, and leave the sections in the dilute solution over 
night. It is advisable to place a piece of filter-paper on the 
bottom of the dish for the sections to rest on, otherwise they 
may be stained on the upper side only. In double stains 
with hematoxylin and carmine the sections should be stained 
first in the hematoxylin and then thoroughly washed in water 
for six to twelve hours before they are stained in the carmine. 
After the carmine they are again to be thoroughly washed in 
water. 

Combination Stains. — Biondi-Heidenhain Stain (see 
p. 250). — Tissues must be hardened in corrosive sublimate. 



HISTOLOGICAL METHODS. 273 

1. Stain paraffin sections six to twenty-four hours with the 
dilute solution. 

2. Wash out a little in 90 per cent, alcohol. 

3. Dehydrate in absolute alcohol. 

4. Xylol. 

5. Canada balsam. 

It is important to place the sections directly from the 
staining fluid into the alcohol, because water washes out the 
methyl-green almost instantly. 

Staining" in Mass. — The staining of tissues in mass is a 
procedure much less employed in pathological than in nor- 
mal histology, but still occasionally useful. For patholog- 
ical tissues a variety of stains is generally necessary. It is 
therefore much better to make a series after one of the 
methods described, and then to stain the sections in what- 
ever way seems best. 

For staining in bulk only a limited number of solutions 
are available — either those, like alum-carmine and alum- 
cochineal, which do not stain beyond a certain point, or 
those, like lithium and borax-carmine and Heidenhain's 
hematoxylin, which may be decolorized so as to leave only 
the nuclei stained, The process of staining differs from that 
for sections only in the length of time required for each step. 
Tissues \ cm. thick will need from one to two days in the 
staining solution. 

MITOSIS. 

For the study of karyomitosis it is important that the 
tissue be perfectly fresh — that is, just removed from a living 
animal or from one just dead — and that it be fixed in a 
suitable reagent as quickly as possible. The best results 
cannot be obtained with tissues put into a hardening fluid 
over half an hour after removal from a living animal. On 
the other hand, mitotic figures can be demonstrated in tissues 
which have been dead for some time (twenty-four hours or 
more) before being put into a fixing reagent, but the details 
of the figures are not so perfect as those in perfectly fresh 
tissues, and the figures are not so numerous, because some 

18 



274 PATHOLOGICAL TECHNIQUE. 

of them have completed their changes and can no longer be 
recognized. It is therefore evident that mitosis can be 
studied much better in tissues from the lower animals, or 
in tissues removed by operation from the human body, 
than in the organs and tissues removed at post-mortem 
examinations. 

The choice of fixing reagents for the study of mitotic 
figures is important. The figures can often be demonstrated 
after hardening in alcohol or even in Miiller's fluid, but for 
their careful study quicker and more perfect fixing reagents 
must be used. Nearly all of the reagents employed pene- 
trate slowly, so that it is absolutely necessary for the best 
results that the tissue to be hardened be cut into very thin 
slices, rarely over 4 mm. in thickness and preferably not over 
2 mm. The amount of fixing reagent used should always be 
at least ten to fifteen times as great as the volume of the 
tissue, and should be changed if it becomes cloudy. 

The most important fixing reagents are — 

1. Flemming's solution. 

2. Hermann's solution. 

3. Pianese's solution. 

4. Zenker's fluid. 

5. Corrosive sublimate. 

6. Orth's fluid. 

The first three solutions penetrate with much difficulty, so 
that tissues placed in them should be especially thin. The 
most generally useful stain for mitosis is probably safranin. 
The time of staining varies with the solution used. Babes' 
is the quickest. The mitotic figures should be stained 
deeply : then, when treated with alcohol slightly acidulated 
with hydrochloric acid, they will retain the color, while the 
resting nuclei will yield up most of theirs and become very 
pale or even colorless. In consequence of this intense stain 
mitotic figures can then be very readily found. 

Directions for Staining Karyomitotic Figures with 
Safranin. — 1. Stain paraffin sections five minutes to twenty- 
four hours, according to solution used. 

2. Wash in water. 



HISTOLOGICAL METHODS. 275 

3. Wash in 95 per cent, alcohol to which are added a few 
drops of acid alcohol. 

4. Wash in pure 95 per cent, alcohol, followed by absolute 
alcohol. 

5. Xylol. 

6. Xylol balsam. 

For celloidin sections, clear in oil of bergamot or oleum 
origani cretici after the 95 per cent, alcohol, wash out in 
xylol, and mount in xylol balsam. Safranin can be used 
after any of the above fixing reagents. 

Other useful stains are carbol-fuchsin and aniline-gentian- 
violet, used in the same way as the safranin. The Gram- 
Weigert method gives good results after Flemming's solu- 
tion. 

After fixing in corrosive sublimate mitotic figures can be 
demonstrated by the Biondi-Heidenhain solution, which 
stains resting nuclei blue-violet and mitotic figures green. 
After Pianese's solution his special staining mixtures should 
be used (see page 250). His methods are said to give 
beautiful results. 

THE STAINING OF BACTERIA IN TISSUES. 

Bacteria are demonstrated in sections of tissues almost 
entirely by means of the aniline dyes, of which three have 
thus far proven themselves to be particularly valuable — 
namely, methylene-blue, gentian-violet, and fuchsin. These 
dyes are employed in aqueous or dilute alcoholic solutions, 
of which the effective staining power is greatly increased by 
means of heat and by the addition to the solutions of certain 
chemical substances. 

The effect of moderate heat is obtained by placing the 
sections in the incubator for several hours, or greater heat 
for a short time is utilized by warming the staining solution 
on the slide over a small flame for a few seconds or minutes, 
keeping the fluid steaming, but not allowing it to boil. 

Of the various methods employed to increase the staining 
power of aniline dyes by means of chemical substances, the 
most successful have been the use of caustic potash with 



2j6 PATHOLOGICAL TECHNIQUE. 

methylene-blue, of aniline oil with gentian-violet and fuchsin, 
and of carbolic acid with fuchsin and methylene-blue. 

For decolorizing sections after they have been stained the 
most commonly employed reagents are — 

1. Acetic acid in dilute aqueous solutions I : ioo, I : iooo. 

2. Alcohol. 

3. Iodin in iodid-of-potash solution (with certain dyes only). 

4. Mineral acids in various strengths. 

5. Chlorid of aniline. 

6. Acid aniline colors added to the alcohol to increase its 
extractive power. 

7. Aniline and ethereal oils. 

The choice of a decolorizer varies with the staining solu- 
tion employed and with the organism that is to be stained. 

Sections which are to be stained for bacteria may be di- 
vided into two classes : 

1. Sections free from celloidin, subdivided into — 

a. Sections cut without an imbedding mass ; 

b. Paraffin sections ; 

c. Sections from which the celloidin has been removed. 

2. Sections infiltrated with celloidin. 

Celloidin imbedding is to some extent a drawback to the 
stains for certain organisms, because the celloidin tends to 
hold the color, so that the bacteria are not so distinct as they 
otherwise would be. Still, it is so important to be able to 
stain bacteria in celloidin sections that particular care is de- 
voted in the following pages to methods which obviate most 
of the difficulties. 

Paraffin sections should, as a rule, be attached to the slide 
by means of Mayer's glycerin-albumin mixture. 

It will usually be found advisable to attach celloidin sec- 
tions to the slide by means of ether-vapor. They will then 
keep perfectly flat in any staining solution, and may be heated 
without danger of wrinkling or contracting. The heat should 
never be applied directly under a section, but at one end of 
the slide. 

All bacteria yet known will stain when placed in appro- 
priate staining solutions. Some, however, are stained quickly, 



HISTOLOGICAL METHODS. 277 

while others are stained with difficulty ; some give up the 
stain readily to decolorizers, while others retain it tenaci- 
ously. In consequence of their reactions to certain dyes and 
to certain decolorizers, bacteria, from the point of view of 
staining, may be divided into three groups : 

1 . Bacteria which do not stain by Gram ; 

2. Bacteria which stain by Gram ; 

3. Bacteria which stain by the tubercle bacillus method. 
Two at least of the organisms in the third group will also 

stain by Gram. The organisms of the second and third 
groups are much more easily demonstrated in tissues than 
those in the first group, because it is possible to stain them 
of one color and the nuclei of the cells of another color. In 
other words, it is possible to stain them so that they are 
differentiated from the tissue in which they lie, and hence 
stand out prominently. 

The organisms of the first group have no differential stain ; 
they take the same color as the nuclei of the tissue. More- 
over, although they stain easily, most of them do not stain 
deeply, and readily part with the color they have taken up. 

Pathogenic Bacteria which do not Stain by Gram. 
(See also page 91.) 

Gonococcus ; 

Diplococcus intracellularis meningitidis ; 

Typhoid bacillus ; 

Glanders bacillus ; 

Bacillus of malignant edema ; 

Influenza bacillus ; 

Capsule bacillus ; 

Colon bacillus ; 

Spirillum of Asiatic cholera. 
Of these organisms certain ones deserve special mention 
on account of their frequent occurrence or on account of the 
difficulty of demonstrating them in tissues, and certain varia- 
tions in staining methods which have proved serviceable will 
be given. Loffler's methylene-blue solution is generally 
considered the most useful stain for this class of bacteria, 



278 PATHOLOGICAL TECHNIQUE. 

but excellent results can also be obtained with Unna's alka- 
line methylene blue solution preceded by eosin, especially 
after fixation in Zenker's fluid. 

Loffler's Methylene -blue Solution. — 1. Stain paraffin 
sections twenty minutes to twenty-four hours. 

2. Wash in weak acetic acid, 1 : 1000, for ten to twenty 
seconds. 

3. Absolute alcohol, two or three changes, to differentiate 
and dehydrate (as a rule, only a few seconds are required for 
this step). 

4. Xylol. 

5. Xylol balsam. 

For celloidin sections use 95 per cent, alcohol ; clear and 
finish the dehydration in oil of bergamot or origanum ; wash 
out the oil with several changes of xylol, and mount in xylol 
balsam. 

This solution of methylene-blue is extremely useful, be- 
cause it will stain all bacteria except the tubercle-bacillus 
group. Other solutions which may be used in the same way 
are — aniline-gentian-violet, Stirling's solution of gentian- 
violet, simple aqueous solutions of gentian- or methyl-violet, 
and Ziehl's carbol-fuchsin. 

Gonococcus. — Loffler's solution gives good results. 

Touton recommends staining sections in carbol-fuchsin and 
washing out in alcohol. 

Typhoid Bacillus. — Typhoid bacilli in stained sections 
are generally best hunted for with a low power. The cha- 
racteristic colonies which they form are easily recognized. 
Good results in staining can be obtained with Loffler's 
methylene-blue solution used in the manner already de- 
scribed, but the stain is never very intense. For rendering 
the bacilli rather more prominent, so that small groups of 
them may be recognized, Flexner has recently advised the 
two following methods : 

A. — 1. Stain paraffin sections in Loffler's methylene-blue 
solution for two hours. 

2. Acetic-acid solution, 1 : 1000, for several minutes. 

3. Dehydrate in absolute alcohol. 



HISTOLOGICAL METHODS. 2JQ 

4. Oil of cloves to clear and differentiate. 

5. Xylol, several changes. 

6. Xylol balsam. 

B. — 1. Stain sections in Stirling's gentian-violet solution 
for ten minutes. 

2. Acetic-acid solution, 1 : 1 000, for some minutes. 

3. Dehydrate quickly in 95 per cent, alcohol. 

4. Transfer to slide, blot, add oil of cloves to clear, and 
differentiate. Change the oil several times until the desired 
differentiation is obtained. 

5. Wash off section several times with xylol. 

6. Xylol balsam. 

Influenza Bacillus.— 1. Harden in alcohol. 

2. Stain half an hour or more in carbol-fuchsin diluted 
with 20 parts of water. 

3. Wash out in a watch-glass of water to which is added 
a drop of glacial acetic acid until the section appears gray- 
violet in color. 

4. Alcohol, oil, balsam. 

Glanders Bacillus. — The bacilli are usually not numer- 
ous, and are scattered about in a mass of deeply-staining 
fragmented nuclei, so that they are recognized with great 
difficulty. 

Loffler's Method for Sections. — 1. Stain paraffin sections 
twenty minutes in Loffler's methylene-blue solution or in 
equal parts of aniline-gentian-violet and 1 : 10,000 KOH 
solution. 

2. Place for five seconds in the following solution : 

Distilled water, 10 c.c. ; 

Concentrated sulphuric acid, 2 drops ; 

5 per cent, oxalic acid, 1 drop. 

3. Wash out quickly in distilled water. 

4. Absolute alcohol. 

5. Xylol. 

6. Xylol balsam. 

It is recommended to place the section for a few minutes 
before staining in the 1 : 10,000 caustic-potash solution. 



280 PATHOLOGICAL TECHNIQUE. 

Schiitz's Method, — i. Stain twenty-four hours in equal 
parts of concentrated alcoholic solution of methylene-blue 
and caustic potash, I : 10,000. 

2. Wash in acidified water. 

3. 50 per cent, alcohol for five minutes. 

4. Absolute alcohol for five minutes. 

5. Xylol. 

6. Canada balsam. 

Noniewicz's Method. — 1. Stain in Loffler's methylene- 
blue solution two to five minutes. 

2. Wash in water. 

3. Decolorize one to five seconds in 

\ per cent, acetic acid, 75 parts ; 

\ per cent, aqueous solution of tropeolin, 25 " 

4. Wash in water. 

5. Dehydrate section on slide with filter-paper; then in 
the air ; finally, over small flame. 

6. Clear by dropping xylol on it repeatedly. 

7. Xylol balsam. 

Friedlander's Capsule-bacillus. — The following meth- 
od is recommended for staining the capsules in sections : 

1. Stain for twenty-four hours in the incubator in the fol- 
lowing solution : 

Concentrated alcoholic solution of gentian-violet, 50 ; 
Distilled water, 100; 

Glacial acetic acid, 10. 

2. Wash out in a 1 per cent, solution of acetic acid. 

3. Alcohol. 

4. Oil. 

5. Canada balsam. 

If the process of decolorization is stopped at the right 
moment, the capsules will be pale blue, while the bacilli 
will be stained deep blue. 

Pathogenic Bacteria which Stain by Gram. 
Micrococcus lanceolatus ; 
Streptococcus pyogenes ; 



HISTOLOGICAL METHODS. 28 1 

Staphylococcus pyogenes aureus, albus, citreus, and flavus ; 

Micrococcus tetragenus ; 

Anthrax bacillus ; 

Bacillus of rhinoscleroma ; 

Diphtheria bacillus ; 

Tetanus; 

Actinomyces ; 

Tubercle bacillus ; | 

Leprosy bacillus, j 

These organisms, with the exception of the tubercle- 
bacillus group, are all readily stained by the general methods 
employed for staining under Group 1. For staining most 
of them in sections, however, the differential Gram-Weigert 
method will be found to give the most satisfactory results. 

The Gram Staining' Method. — Directions for staining 
paraffin sections : 1. Stain in aniline-gentian-violet five to 
twenty minutes. 

2. Wash in normal salt solution or water. 

3. Iodin solution (1:2: 300) one minute. 

4. Wash in water. 

5. Absolute alcohol, several changes, until no more color 
is given off and the section is apparently decolorized. 

6. Xylol. 

7. Xylol balsam. 

This method is not suited for celloidin sections, because 
the alcohol does not decolorize the celloidin sufficiently. In 
fact, it is better to reserve Gram's method for cover-slip 
work alone, and to use instead of it, for sections of all kinds, 
Weigert's modification. This consists simply in the use of 
aniline oil instead of alcohol as a decolorizer. The method 
is easily acquired, is perfectly adapted to celloidin sections, 
and the results are more perfect than after Gram. 

The Gram-Weigert Staining* Method. — Directions for 
staining celloidin sections: 1. Stain sections with lithium 
carmine in the ordinary way (see page 244). 

2. After dehydrating in 95 per cent, alcohol stick the sec- 
tion to the slide with ether-vapor. 

3. Stain in aniline-gentian-violet five to twenty minutes. 



282 PATHOLOGICAL TECHNIQUE. 

4. Wash off excess of stain in normal salt solution. 

5. lodin solution (1:2: 100) one minute. 

6. Wash off in water. 

7. Blot section with filter-paper to remove as much of the 
moisture as possible. 

8. Aniline oil, several changes, to dehydrate and to re- 
move all excess of color. 

9. Xylol, several changes to remove the aniline oil com- 
pletely. 

10. Xylol balsam. 

Bacillus of Rhinoscleroma.— Method of staining cap- 
sules in sections of tissues hardened in alcohol (Wolko- 
witsch) : 1. Stain twenty-four to forty-eight hours in aniline- 
gentian-violet. 

2. Wash off in water. 

3. Iodin solution one to four minutes. 

4. Absolute alcohol. 

5. Oil of cloves, which removes still more of the color. 

6. Xylol. 

7. Canada balsam. 

According to Wolkowitsch, the hyaline masses in rhino- 
scleroma stain intensely with methyl-violet, gentian-violet, 
methylene-blue, and fuchsin ; less with safranin, and not at 
all with hematoxylin. Eosin stains them well. Double 
staining with hematoxylin and eosin is therefore to be 
recommended highly. 

Actinomyces. — In staining actinomyces it is important 
to stain not only the filaments and other forms of the organ- 
ism, but also the hyaline swollen sheaths which surround 
the ends of the filaments. It is believed that the two fol- 
lowing methods will give better results than can be obtained 
by any of the methods previously published for this purpose. 
The first is, perhaps, the better and surer, although the clubs 
are sometimes brought out more intensely by the second 
method. 

Method No. 1 (Mallory). — 1. Stain sections deeply in a 
saturated aqueous solution of eosin for at least ten min- 
utes. 



HISTOLOGICAL METHODS. 283 

2. Wash off in water. 

3. Stain in aniline-gentian-violet two to five minutes. 

4. Wash off with normal salt solution. 

5. Iodin solution (1:2: 100) one minute. 

6. Water. Blot with filter-paper. 

7. Aniline oil till section is clear. 

8. Xylol, several changes. 

9. Xylol balsam. 

A light preliminary stain with alum-cochineal will often be 
found useful. 

Method No. 2 (Mallory). — 1. Stain lightly in alum-coch- 
ineal three to five minutes. 

2. Wash in water. 

3. Dehydrate in 95 per cent, alcohol. 

4. Fasten section to slide with ether-vapor. 

5. Aniline-gentian-violet five to twenty minutes. 

6. Wash off with water. 

7. Dry with filter-paper. 

8. Aniline saturated with fuchsin one to three minutes. 

9. Wash out the fuchsin with pure aniline until the clubs 
are sharply differentiated : watch the process under the low 
power of the microscope. 

10. Xylol, several changes. 

11. Xylol balsam. 

The polymorphous bacterium is stained blue, the swollen 
membrane (the club), light to dark pink. Alum-cochineal 
furnishes a better contrast to the actinomyces than either 
alum-carmine or alum-hematoxylin. By these methods it is 
possible to demonstrate in sections containing young colonies 
the ends of the threads stained blue surrounded by the 
swollen cell-membrane stained pink. 

Bacteria that Stain by the Tubercle Bacillus Method. 

Tubercle bacillus ; 
Leprosy bacillus ; 
Smegma bacillus ; 
Syphilis bacillus. 
The important point about staining tubercle bacilli is to 



284 PATHOLOGICAL TECHNIQUE. 

stain them deeply enough in the beginning ; then there is 
little danger of their fading in the subsequent steps of con- 
trast-staining. It is probable that carbol-fuchsin, used hot, 
is the most powerful stain we have for this purpose. If the 
solution is steamed, generally on the slide, one to five min- 
utes are probably sufficient for all purposes. Tubercle bacilli 
stain well, not only after alcohol, but also after most of the 
other fixing reagents, such as corrosive sublimate, Zenker's 
fluid, Flemming's solution, etc. 

Ehrlich's Method. — 1. Stain paraffin sections in aniline- 
fuchsin or gentian-violet for half an hour to twenty-four 
hours, or for one to five minutes if solution is heated to 
steaming. 

2. Wash in water. 

3. Decolorize in 20 per cent, nitric acid one-half to one 
minute. 

4. Wash in 70 per cent, alcohol until no more color is 
given off. 

5. Contrast-stain in a saturated aqueous solution of meth- 
ylene-blue or of Bismarck brown one to two minutes. 

6. Wash in water. 

7. Dehydrate in absolute alcohol. 

8. Xylol, xylol balsam. 

Ziehl-Neelson-G-abbet Method. — 1. Stain paraffin sec- 
tions in carbol-fuchsin solution, warming the solution so that 
it steams one to three minutes. 

2. Wash in water. 

3. Decolorize and stain for contrast in sulphuric-acid- 
methylene-blue solution one minute (see page 246). 

4. Wash in water. 

5. Absolute alcohol. 

6. Xylol. 

7. Xylol balsam. 

This method is not suited to celloidin sections, because 
the celloidin retains too deep a blue stain. 

Kiihne's Method. — 1. Stain paraffin sections lightly in 
alum-hematoxylin. 

2. Wash in water. 



HISTOLOGICAL METHODS, 285 

3. Stain in carbol-fuchsin one to five minutes if warmed; 
longer if cold. 

4. Wash in water. 

5. Aniline hydrochlorate, 2 per cent, aqueous solution, fif- 
teen seconds. 

6. Wash in water. 

7. Absolute alcohol. 

8. Xylol. 

9. Xylol balsam. 

To Stain Tubercle Bacilli in Celloidin Sections. — 1. 
Stain rather lightly in alum-hematoxylin. 

2. Wash in water. 

3. Carbol-fuchsin five to twenty minutes cold; one to five 
minutes steaming. 

4. Water. 

5. Orth's discharging fluid (acid alcohol) one-half to one 
minute. 

6. Wash in several changes of water to remove acid thor- 
oughly and to bring back blue color to nuclei. 

7. Alcohol 95 per cent, until fuchsin is entirely discharged. 

8. Aniline. 

9. Xylol, several changes. 

10. Xylol balsam. 

The advantages of this method are — that the celloidin is 
colorless : the nuclei are stained blue ; the rest of the tissue 
is colorless ; the tubercle bacilli stand out in sharp contrast. 
It is sometimes an advantage to bring out the cell-proto- 
plasm and the intercellular substance by staining the sec- 
tions, after decolorization in alcohol, in an aqueous solution 
of orange G or methyl-orange for a few seconds. 

The bacillus of leprosy stains more easily than the 
tubercle bacillus. Simple aqueous solutions of the aniline 
dyes are sufficient. The same methods can be employed as 
for tubercle bacilli. Baumgarten gives the following differ- 
ential stain for leprosy bacilli : 

1. Stain six to seven minutes in a dilute solution of fuch- 
sin (5 drops of a concentrated alcoholic solution to a watch- 
glass of water). 



286 PATHOLOGICAL TECHNIQUE. 

2. Discharge one-quarter minute in nitric-acid alcohol 
(nitric acid i, alcohol 10). 

3. Wash in water. 

4. Contrast-stain in a saturated aqueous solution of meth- 
ylene-blue. 

5. Alcohol. 

6. Xylol. 
7; Balsam. 

While leprosy bacilli stain readily by this method, tubercle 
bacilli will not stain in so short a time. 

Syphilis Bacillus. — Lustgarten's Method. — 1. Stain 
twenty-four hours at room-temperature and two hours in the 
thermostat at 40 in aniline-gentian-violet. 

2. Wash off in absolute alcohol three to five minutes. 

3. Decolorize (a) in a \ per cent, aqueous solution of per- 
manganate of potassium, and then (b) a few seconds in an 
aqueous solution of pure sulphurous acid (strength not 
given). 

4. Wash in water. 

5. Alcohol. 

6. Oil of cloves. 

7. Canada balsam. 

If the section is not entirely decolorized when the section 
is put into water, then the third step must be repeated until 
decolorization is complete. If desired, the sections can be 
stained in safranin after the fourth step. 

Giacomi's Method. — 1. Stain several minutes in hot ani- 
line-fuchsin. 

2. Wash out in very dilute aqueous solution of chlorid of 
iron. 

3. Decolorize in concentrated solution of chlorid of iron. 

4. Wash out in absolute alcohol. 

5. Xylol. 

6. Xylol balsam. 

The smegma bacillus is stained by Lustgarten's method, 
but not by the methods given for tubercle bacilli in tissues, 
because in all of them alcohol is used as well as an acid to 
effect the decolorization. 



HISTOLOGICAL METHODS. 287 

METHODS OF EXAMINATION OF ANIMAL PARASITES. 

Protozoa. — Of the rhizopoda, the malarial organisms and 
the ameba coli are of much pathological interest. 

Malarial Organisms. — Three varieties of the plasmodium 
malariae have been described — namely, the tertian, quartan, 
and estivo-autumnal parasites. They develop within the red 
corpuscles and cause the destruction of the corpuscles af- 
fected. The earliest forms of the parasite appear in the 
blood during the latter part of the malarial paroxysm or 
shortly after it. At this time they appear as small, color- 
less, disc-shaped hyaline bodies which occupy but a small 
portion of the blood-corpuscles. They possess a varying 
degree of ameboid movement, the amount depending upon 
the type of the organism. These ameboid movements are 
best observed on the warm stage. During the process of 
development the parasites increase in size and more or less 
completely fill the red corpuscles containing them. Small 
particles of reddish-brown pigment are produced, during 
their growth, from the hemoglobin of the corpuscles in 
which the organisms are developing. These granules show 
varying degrees of motion, probably imparted to them by 
the movements of the parasites. At first the pigment ap- 
pears to be scattered about in the corpuscle, but it is in real- 
ity in the extremities of the pseudopodia. Later it appears 
more evenly spread about in the periphery. Toward the 
end of the cycle of development the pigment collects in the 
center of the parasite ; at this time the ameboid movements 
have ceased, indications of segmentation occur, and the 
parasite nearly or completely fills the corpuscle. Oftentimes 
at this stage only a small portion of the corpuscle is visible 
at some point on the edge of the parasite. 

The beginning of segmentation is indicated by a number 
of radial lines extending from the periphery of the parasite 
toward the central clump of pigment. Segmentation takes 
place, and the pigment is surrounded by a number of dis- 
tinct segments which vary with the type of the organism. 
Each of these segments shows a central refractive spot 



288 PATHOLOGICAL TECHNIQUE. 

which probably is the nucleus. At this time one notices 
small hyaline bodies, like those of the early stage in the de- 
velopment of the parasite, in some of the red blood-cor- 
puscles. Oftentimes such a regular process of segmentation 
is not observed, but enough has been said to indicate the 
manner in which reproduction occurs. Segmentation is the 
indication of an approach of a paroxysm. Extra-cellular 
forms of the parasites are not infrequently seen. They may 
be fully-grown organisms which have destroyed the cor- 
puscles that contained them, or they may be partly-grown 
organisms which have left the corpuscles. These free para- 
sites are indistinct in outline and contain pigment. They 
possess ameboid movements, and may be considerably larger 
than a red blood-corpuscle. Various changes are observed 
in them : 

1. They may increase in size until they become nearly as 
large as polymorphonuclear leucocytes. With the increase 
in size there is a gradual cessation in the movement of the 
pigment-granules until finally the organisms present the ap- 
pearance of misshapen masses of protoplasm containing 
motionless pigment-granules. 

2. They may undergo fragmentation and give off several 
small circular pigmented bodies. 

3. Vacuolization may occur. 

4. Flagellate forms may develop. One or more thread- 
like processes are thrust out from the organisms. These 
flagella may contain pigment, and may break away from the 
organism and move about among the corpuscles, looking not 
unlike the spirilla of relapsing fever. 

The three varieties of parasites differ from each other in 
a number of ways. The chief differences are the length of 
the cycle of development ; the size of the full-grown organ- 
isms ; the difference in the refractibility of the organisms ; 
the quantity, size, and color of the pigment-granules ; the 
degree of ameboid movement ; and the number and shape 
of the segments into which the full-grown organisms divide. 
In the earliest stage the varieties of organisms cannot be dis- 
tinguished from each other. 



HISTOLOGICAL METHODS. 289 

The tertian parasite completes its cycle of development in 
about forty-eight hours. When it has attained its fullest 
growth it almost fills the corpuscle, which has become 
larger than normal. This organism is less refractive than 
either of the other two. The pigment-granules are more 
numerous, finer, and more reddish-brown in color ; the ame- 
boid movements are much more active ; the segments are 
more irregular in shape and more numerous than those of the 
quartan parasite, varying from twelve to twenty in number. 

The quartan appears to complete its cycle of development 
in from sixty-four to seventy-two hours. The full-grown 
organism does not fill completely the corpuscle, and the latter 
is not increased in size. The organism is more refractive 
than the tertian parasite. The pigment-granules are fewer 
in number, coarser, and have a darker-red color. The ame- 
boid movements are slower ; the segments are pear-shaped, 
more symmetrical, and less numerous than those of the ter- 
tian parasite, varying from six to twelve in number. Seg- 
menting organisms are more numerous in the peripheral 
circulation than in the case of the tertian parasite. 

The estivo-autumnal parasite cannot be studied so thor- 
oughly in the peripheral circulation, because the later develop- 
ment and segmentation take place in the internal organs. The 
length of time required to complete its cycle of development 
is not so definitely settled. It appears to require from twelve 
to twenty-four hours, more or less. The full-grown organ- 
ism is smaller than the tertian parasite, and the corpuscle 
which contains it is often smaller than normal and more or 
less distorted. The parasite is quite refractive. The pig- 
ment-granules are few in number and coarse. The ameboid 
movements are slow. After the duration of fever for from 
five days to a week or' more, elongated, ovoid, or crescent- 
shaped bodies make their appearance. They are sometimes 
as large or larger than a red corpuscle. These bodies are 
not a result of segmentation, but appear to be a further de- 
velopment of the round hyaline bodies. They are highly 
refractive and contain granules of coarse pigment m the 
center. They lie usually at one side of the red corpuscles, 
19 



29O PATHOLOGICAL TECHNIQUE. 

the latter more or less completely filling the concavity be- 
tween the two horns of the crescent. They may lie in the 
center of the corpuscles. Some of the apparently free ovoid 
bodies are turned in such a way as to present a convex sur- 
face toward the observer. 

Double infections occur quite frequently in both tertian 
and quartan fever, and in the latter not infrequently triple 
infections occur. In the double infections two groups of 
parasites reach maturity on successive days and cause daily 
febrile paroxysms. In the triple infection of quartan fever 
three groups of organisms mature on successive days and 
cause corresponding paroxysms. 

Methods of Examining the Blood for Malarial Organisms. 
— The organisms of malaria can be detected in fresh speci- 
mens of blood or in specimens of blood which have been 
fixed and stained. The examination of fresh specimens of 
blood is simpler and more reliable, because the development 
of the parasites can be observed. 

The method employed in making cover-glass preparations 
of the blood has been thoroughly described (see preparation 
of cover-glass specimens in the Examination of the Blood, 
page 336). 

In examining a fresh specimen of the blood for the malarial 
organisms a glass slide is substituted for one of the cover- 
glasses, and the cover-glass which has the drop of blood on 
its surface is dropped lightly upon the glass slide and allowed 
to remain there. The first four or five drops of blood 
should be quickly wiped away from the ear until a very 
small drop is obtained. Great care must be exercised to 
touch only the tip of the drop with the cover-glass, so as to 
avoid smearing the blood. If the blood is smeared on the 
cover-glass, the edges of the blood-drop will dry before the 
cover-glass can be transferred to the slide, and the blood will 
not spread. It is necessary that the blood should spread in 
a thin layer in order to study satisfactorily the individual 
corpuscles. If one desires to study the preparation for 
several hours, the edges of the cover-glass can be sur- 
rounded by melted paraffin or vaselin to exclude the air. 



HISTOLOGICAL METHODS. 29 1 

The examination should be made with an oil-immersion lens. 
It should be remembered that the action of cold inhibits the 
ameboid movements of the parasites ; it may be necessary, 
therefore, at times to warm the slide before examining the 
specimen. Evaporation not infrequently occurs, caused by 
the air penetrating beneath the cover-glass. This produces 
changes in many of the corpuscles which may be mistaken 
for hyaline bodies : the central depression becomes paler and 
less refractive than the periphery of the corpuscles ; later a 
number of corpuscles contain small glistening points, and 
still later the corpuscles become crenated. 

The method of procuring permanent cover-glass prepara- 
tions is the same as that elsewhere described (see Cover- 
glass Preparations, page 336). Specimens may be fixed by 
heating or by a mixture of absolute alcohol and ether, equal 
parts. Numerous methods of staining have been employed. 
The following methods are simple and satisfactory : The 
fixed cover-glass preparation is stained from one to two 
minutes in a concentrated aqueous solution of methylene- 
blue. The staining solution should be filtered before using. 
The specimen is thoroughly washed in water, dried, and 
mounted in Canada balsam. This stains the organisms and 
the nuclei of the white corpuscles blue. The red corpuscles 
are unstained. 

A good contrast-stain can be obtained with eosin and 
methylene-blue. The fixed specimens are stained for from 
thirty seconds to five minutes in a J per cent, solution of 
eosin in 60 per cent, alcohol, washed in water, dried, and 
placed for from thirty seconds to one minute in a concen- 
trated aqueous solution of methylene-blue, washed, dried, 
and mounted in Canada balsam. The red corpuscles are 
stained a bright red by the eosin, and the organisms and the 
nuclei of the white corpuscles are stained blue. 

Excellent results are obtained by Romanowsky's method. 
This method is as follows : A saturated aqueous solution 
of methylene-blue and a 1 per cent, aqueous solution of 
eosin are kept separately. The older the methylene-blue 
solution the better the results. The specimen is then heated 



292 PATHOLOGICAL TECHNIQUE. 

not less than thirty minutes at a temperature of from 105 ° 
to no° C. The staining mixture is made just before it is 
to be used. To 1 part of the filtered methylene-blue solu- 
tion are added about 2 parts of the eosin solution. This 
mixture is carefully stirred with a glass rod, but not filtered, 
and poured into a watch-glass. The cover-glass prepara- 
tions are allowed to float upon the top of the fluid with the 
blood surface down. The specimens are covered by another 
inverted glass, and the whole by an inverted cylinder which 
is moistened upon the inside. Good specimens are obtained 
in from one-half to three hours. Romanowsky believes 
that he obtains thus three colors : the red corpuscles stained 
red by the eosin, the malarial parasites a Prussian blue by 
the methylene-blue, and the nuclear chromatin a violet color 
(a neutral stain). Thayer and Hewitson claim to have ob- 
tained their best results by means of a slight modification of 
Romanowsky's method. The modification consists in fixing 
the specimens in absolute alcohol for from ten to twenty 
minutes instead of employing heat. 

In the fixed and stained specimens there is always a possi- 
bility of mistaking small particles of methylene-blue, which 
have passed through the filter-paper, for malarial organisms. 
Sometimes these particles lie on the red corpuscles, and it is 
difficult to determine whether they are inside of the cor- 
puscles or lying on the surface. 

Note. — The description of the development of the parasites is abstracted 
from Thayer and Hewitson's The Malarial Fevers of Baltimore. 

Ameba Coli. — In cases of dysentery suspected of being 
due to the ameba coli (Fig. 88) the stools are best examined 
as soon as voided, although the amebae will sometimes re- 
main active in stools even over twenty-four hours old. A 
warm stage during the examination is an advantage, but not 
a necessity. A drop of the fluid material, preferably that 
containing mucus or blood, is placed on a slide and lightly 
covered with a cover-glass. If the slide is cold and the or- 
ganisms do not move, warm the slide gently and the move- 
ments of the amebae will often start up. Pus from abscesses 
due to the amebae is examined in the same way. A positive 



HISTOLOGICAL METHODS. 



293 



diagnosis rests on the presence of the characteristic large, 
pale cells, consisting of nucleus, granular endosarc, and 
hyaline ectosarc, and on the movements of the protoplasm, 
which projects itself more or less actively in the form of 
pseudopodia. 

In hardened preparations the nuclei of the amebae do not 
stain with the ordinary nuclear stains, such as alum-hema- 
toxylin and methylene-blue. The following method of stain- 




'■■mmm 

- tVi.v. .j ■■■■■-■ ,. >• 

Fig. 88. — Amebae coli in intestinal mucus (after Losch). 

ing them has been found to give very satisfactory results 
and to render the recognition of the organisms easy : 

Differential Stain for the Ameba Coli(Mallory). — 1. Harden 
in alcohol. 

2. Stain sections in a saturated aqueous solution of thionin 
three to five minutes. 

3. Differentiate in a 2 per cent, aqueous solution of oxalic 
acid for one-half to one minute. 

4. Wash in water. 

5. Dehydrate in alcohol. 

6. Clear in oleum origani cretici. 

7. Wash off with xylol. 

8. Xylol balsam. 

The nuclei of the amebae and the granules of the mast- 
zellen are stained brownish red ; the nuclei of the mastzellen 
and of all other cells are stained blue. 

Excellent results were obtained by this method with bits 



294 PATHOLOGICAL TECHNIQUE. 

of the purulent discharge from a so-called amebic abscess 
of the liver. After hardening in 95 per cent, alcohol, small 
fragments the size of a pin-head and less were stained as 
above directed, and teased apart after they were in the 
balsam. The reddish nuclei stood out so sharply in the 
bluish background of fragmented nuclei and granular de- 
tritus that they were easily picked out with the high dry 
power. 

The results obtained with feces examined in the same way 
or after imbedding in celloidin were much less satisfactory, 
for the reason that various substances in the feces precipitate 
the thionin in the form of reddish crystals and give rise to 
deceptive pictures. A similar differential stain can be ob- 
tained by Unna's method for staining the granules of mast- 
zellen (see page 300). 

Other protozoa, such as the cercomonas and trichomonas, 
are best examined in fresh preparations. 

Sporo^oa. — The coccidium oviforme should be examined 
both fresh in cover-slip preparations and in sections after 
hardening. The cyst-forms often stain well by the tubercle- 
bacillus method. For studying all the stages in the develop- 
ment of the organism Pianese recommends highly his special 
fixing reagent and stains (see p. 225). Other sporozoa 
should be studied in the same manner. Cover-slip prep- 
arations are often useful. 

Round- worms. — The embryos of the filaria sanguinis 
hominis (Fig. 89) are examined for in suspected cases by 

mounting a drop of the fresh 
blood or of the chylous or 
bloody urine on the slide and 
examining under a low power. 
They are readily detected when 
present on account of their 
very active movements. They 

FIG. 89. — Filaria sanguinis hommis J _ J 

(after von jaksch). should be looked for during 

the resting hours of the pa- 
tient, as at night for day-workers and during the day for 
night-workers. 




HISTOLOGICAL METHODS. 



295 



Trichinae (Figs. 90, 91) are obtained from the fresh muscle 
by means of teasing. A quick method is to squeeze small 
bits of tissue between two slides and examine with a low 
power. Pieces of muscle nearest the insertion of the ten- 





FlG. 90. — Living embryos 
(Heller). 



FlG. 91. — Encapsulated trichina 
(Leuckart). 



don are chosen from the diaphragm or from the muscles 
of the jaws. Encapsulated and calcified trichinae are cleared 
up by means of acids. 






ABC 
Fig. 92. — Taenia solium : A, head enlarged ; B, ripe joint, X 6 ; C, egg of taenia 
solium (Heller). 

In hardened tissues the trichinae are best studied in longi- 
tudinal sections of the muscle-fibers. 

The other round-worms which sometimes occur in the 



296 



PA THOL O GICAL TECHNIQ UE. 



intestinal tract can be recognized with the naked eye. Their 
eggs must be looked for with the microscope. 

Tape-worms. — It is not always easy to recognize the 
kind of tape-worm by a single segment passed with the feces, 
because the uterus, which furnishes the most characteristic 






A B C 

Fig. 93. — Taenia mediocanellata : A, head darkly pigmented ; B, ripe joint, X 6 ; 
C, egg of taenia mediocanellata. 

points of difference, is not developed in the young segments 
and is atrophied in the old ones. When the whole worm is 
obtained the problem is much simpler. The uterus is best 
made out by squeezing a segment between two slides and 




^ 
f 



Fig. 94. — Echinococcus : solices, hooks (Heller). 

holding it up to the light. The heads are examined under 
the microscope in water, salt solution, or glycerin. 

Taenia Solium (Fig. 92). — Head has four suckers and a 



HIS TO L O GICAL ME THODS. 



29; 



circle of hooklets ; uterus is noticeably but little branched. 
The genital tract opens laterally. The eggs develop into the 
cysticerci cellulosae, which are not infrequently found in man. 




FIG. 95.— Bothriocephalus latus : A, head ; B, ripe joint, x 6 ; C, egg of bothrio- 
cephalus latus (Heller) ; D, egg with developed embryo (Leuckart). 

The scolex is obtained for examination by tearing open the 
cyst and examining the inner wall. The suckers and hook- 




Fig. 96. — Segments of taenia 
saginata (after Stein). 



Fig. 97. — Segments of Fig. 98. — Segments 
bothriocephalus latus of taenia solium (after 
(after Stein). Stein). 



lets are best studied after mounting fresh and pressing under 



a cover-glass. 



298 



PA THOL O GICAL TECHNIQ UE. 



Taenia Mediocanellata s. Saginata (Fig. 93). — Head has 
four strong suckers, but no hooklets ; uterus is very much 
branched, segments show marked muscular development. 
The genital tract opens laterally. The eggs develop into 
cysticerci, which do not occur in man. 

Taenia Echinococcus (Fig. 94) occurs in dogs. The echin- 
ococcus cysts which occur in man are recognized by the 
very characteristic laminated structure of the cyst-wall. The 
heads of the scolices have four suckers and a double circle 
of hooklets. 

Bothriocephalus Latus (Fig. 95). — The opening of the 





a b c d e 

Fig. 99. — Comparative size of eggs of intestinal parasites : a, taenia solium ; 
b, taenia mediocanellata ; c, ascaris lumbricoides ; d, trichocephalus dispar ; e, oxy- 
uris vermicularis (after Striimpell). 

genital tract lies in the median line. The head is flattened, 
and has two small suckers situated at the sides. 



SPECIAL STAINS FOR CERTAIN TISSUE=ELEMENTS 
OTHER THAN NUCLEI. 

MASTZELLEN. 

Mastzellen are found in the connective tissue, more 
especially in chronic inflammatory processes. Their proto- 
plasmic granules stain intensely like bacteria with the basic 
aniline dyes. Several methods of staining the granules are 
given. With Unna's stains for plasma-cells a differential 
color-stain is obtained for the granules of the mastzellen. 

Ehrlich's Method. — A. General Stain. — Harden in al- 
cohol 



HISTOLOGICAL METHODS. 299 

1. Stain with a saturated aqueous solution of dahlia. 

2. Wash out with acidified water. 

3. Dehydrate in alcohol; clear and mount in Canada 
balsam. 

B. Specific Stain. — Only the protoplasmic granules are 
stained. Harden in alcohol. 

1. Stain twelve hours in — 

Absolute alcohol, 50 c.c. 

Water, 100 " 

Glacial acetic acid, 12.5 " 

Dahlia, q. s., so that the 
solution is almost saturated. 

2. Wash out in alcohol, clear, and mount. 

C. Ehrlich- Westphal Method. — Nuclei red ; granules blue. 
Harden at least a week in alcohol. 

1. Stain in the following solution twenty-four hours : 
Alum-carmine solution, 200; 
Saturated solution of dahlia in absolute alcohol, 200 ; 
Glycerin, 100; 
Glacial acetic acid, 20. 

(Stir repeatedly, then allow the mixture to stand for some 
time.) 

2. Decolorize for twenty-four hours in absolute alcohol. 

3. Oil, Canada balsam. 

Unna's Isolated Stains for Mastzellen. — Harden in 
alcohol. 

A. — 1. Stain in polychrome methylene-blue solution, plus 
a little alum, for three hours to over-night. 

2. Wash in water. 

3. Absolute alcohol, oil of bergamot, balsam. 

B. — 1. Stain in polychrome methylene-blue solution one- 
quarter of an hour. 

2. Wash in water. 

3. Decolorize in glycerin-ether mixture for five to ten 
minutes. 

4 Wash a long time in water. 
5. Absolute alcohol, oil, balsam. 



300 PATHOLOGICAL TECHNIQUE. 

PLASMA=CELLS. 

These are certain cells, much studied by Unna, which are 
very abundant in subacute and chronic pathological pro- 
cesses, and which are characterized by a protoplasm that 
stains quite deeply in alkaline methylene-blue solutions. 
The two methods best suited for their demonstration furnish 
at the same time a differential color-stain for mastzellen. 
The granules of the latter are stained red, the plasma-cells 
are stained blue. 

Unna's Differential Stains for Plasma-cells and Mast- 
zellen. — Harden tissues in absolute alcohol. 

A. — I. Stain paraffin sections in polychrome methylene- 
blue one-quarter of an hour to over-night. 

2. Decolorize in a small dish of water, to which are added 
a few drops of glycerin-ether mixture. 

3. Wash thoroughly in water. 

4. Absolute alcohol, oil of bergamot, balsam. 

B. — 1. Stain in polychrome methylene-blue solution five 
to fifteen minutes. 

2. Wash in water. 

3. Decolorize and dehydrate in a \ per cent, alcoholic 
solution of neutral orcein (about fifteen minutes). 

4. Absolute alcohol, oil of bergamot, balsam. 

CONNECTIVE=TISSUE FIBRILL/E. 

Van Gieson's picro-acid-fuchsin solution is much employed 
for staining connective-tissue fibrillar, but is much better 
adapted for the coarse than for the fine fibrillae, which it 
often fails to stain sharply. The proportions given are those 
recommended by Freeborn. Occasionally it will be found 
necessary to increase the proportion of the acid-fuchsin. 

1. Harden in chrome salts or in corrosive sublimate. The 
results after alcohol are not so good. 

2. Stain deeply in alum-hematoxylin. 

3. Wash in water. 

4. Stain for three to five minutes in 

1 per cent, aqueous solution of acid fuchsin, 5 c.c. 
Saturated aqueous solution of picric acid, 100 " 



HISTOLOGICAL METHODS. 30 1 

5. Dehydrate in 95 per cent, alcohol. 

6. Oleum origani cretici. 

7. Canada balsam. 

Ribbert's Method for Connective-tissue Fibrillae. — 1. 
Fixation in alcohol is preferable. 

2. Place sections in a 10 per cent, solution of phospho- 
molybdic acid for five to thirty seconds (use glass or plati- 
num needles). 

3. Wash quickly in water. 

4. Stain five minutes or less in phosphomolybdic acid 
hematoxylin. (For this purpose the solution can be used 
after it is twenty-four hours' old.) 

5. Water. 

6. Alcohol, oil, Canada balsam. 

Fibrillar deep blue ; other tissue-elements grayish-green ; 
contrast-stains incompatible. The method is recommended 
for staining the finest fibers of connective tissue. 

Unna's Method for the Connective-tissue Fibrillae. — 1. 
Harden in alcohol. 

2. Stain in the concentrated solution of polychrome methyl- 
ene-blue five minutes. 

3. Wash in water. 

4. Decolorize, differentiate, and stain in a 1 per cent, solu- 
tion of orcein in absolute alcohol fifteen minutes. 

5. Wash in absolute alcohol. 

6. Oil of bergamot. 

7. Balsam. 

Nuclei, dark blue ; protoplasm, pale blue ; elastic and con- 
nective-tissue fibers, deep orcein red ; smooth muscle-fibers, 
bluish ; mastzellen granules, red : protoplasm of plasma cells, 
deep blue. 

ELASTIC FIBERS. 

Elastic fibers are not affected by dilute caustic soda or 
potash or by acids. They show a marked affinity for osmic 
acid, staining with greater rapidity than most other tissue- 
elements. They also show much affinity for certain aniline 
dyes, such as Victoria blue and safranin, but much depends 



302 PATHOLOGICAL TECHNIQUE. 

on the exact sort used. Phosphotungstic-acid hematoxylin 
and Unna's orcein method will be found to give very satis- 
factory results. 

A. Staining of Elastic Fibers with Phosphotung-stic- 
acid Hematoxylin (Mallory) (see page 243). — Harden in 
alcohol. The results after other fixatives do not seem so 
good. 

1. Stain sections in phosphotungstic-acid hematoxylin 
twenty-four hours. 

2. Wash in water. 

3. Alcohol. 

4. Oil, Canada balsam. 

Nuclei and elastic fibers, blue ; connective tissue, pink. 

B. Unna's Orcein Method for Elastic Fibers. — Unna's 
latest method of using orcein is as follows, and can be highly 
recommended : 

1. Stain sections in the following solution : 

Orcein (Grubler), 1 ; 

Hydrochloric acid, 1 ; 

Absolute alcohol, 100. 

Place the sections in a dish and pour over them enough 
of the solution to cover them. Warm gently in an incubator 
or over a small flame for ten to fifteen minutes until the 
solution thickens, or leave in the solution at room-tempera- 
ture over night. 

2. Wash off thoroughly in dilute alcohol (70 per cent.). 

3. Wash in water to get rid of all the acid and to fix the 
color. 

4. Alcohol. 

5. Oil. 

6. Balsam. 

The washing in water is not absolutely essential. 

Elastic fibers are stained of a deep silky-brown color, con- 
nective tissue a pale brown. If it is desirable to have only 
the elastic fibers stained, wash for a few seconds in 1 per 
cent, hydrochloric-acid alcohol before washing in water. 
The nuclei can be brought out by staining in Unna's poly- 



HISTOLOGICAL METHODS. 303 

chrome methylene-blue solution after washing the sections in 
water. 

C. Another method of Unna's is the following : 1 . Harden 
in alcohol or Flemming's solution. 

2. Stain first, if desired, in vesuvin. 

3. Wash in water. 

4. Stain twenty-four hours in — 

Fuchsin, 0.5 ; 

Distilled water, 25. ; 

Alcohol, 25.; 

Nitric acid (25 per cent), 10. 

5. Two to three seconds in 25 per cent, nitric acid. 

6. Decolorize in weak acetic acid. 

7. Dehydrate quickly in absolute alcohol. 

8. Xylol, Canada balsam. 

D. Herxheimer's Method. — 1. Harden in Muller's fluid; 
alcohol and other fixatives are not so good. 

2. Stain three to five minutes in — 

Hematoxylin, 1 ; 

Absolute alcohol, 20 ; 

Water, 20 ; 

Cold saturated solution of carbonate of lithium, 1. 

3. Decolorize for from five to twenty seconds in the offi- 
cinal solution of chlorid of iron. 

4. Wash in water. 

5. Alcohol, oil, Canada balsam. 

Elastic fibers, blue black and deep black ; the surrounding 
tissue, pale blue to blue. 

THE CENTRAL NERVOUS SYSTEM. 

In the preservation of the central nervous system the 
special structures which require consideration are the gang- 
lion-cells, including both the dendritic and the axis-cylinder 
processes, the myelin sheaths, and the neuroglia-fibers. No 
one fixing reagent is suited for the best preservation of all 
of them, unless possibly it be formaldehyde. 



304 PATHOLOGICAL TECHNIQUE. 

The main fixing fluids for the nervous system until within 
a very short time have been various solutions of the chrome 
salts, particularly of bichromate of potassium, either alone 
or in combination with sulphate of sodium, as in the well- 
known Muller's fluid. The chief objections to the chrome 
salts as fixatives are that they penetrate and harden very 
slowly, and do not preserve properly either the ganglion- 
cells or the neuroglia-fibers. On the other hand, they prob- 
ably preserve the axis-cylinders as well as any reagent we 
yet know, and are invaluable for their property of entering 
into some chemical combination with myelin, in consequence 
of which it is possible to obtain by the method originated 
by Weigert a differential stain of the myelin sheaths. 

The new fixing reagent, formaldehyde, seems likely to find 
its greatest use histologically as a fixative of the central 
nervous system. It penetrates and hardens up to a certain 
degree with great rapidity. It also preserves in certain struc- 
tures the special chemical properties on which certain differ- 
ential stains depend. Small pieces of nervous tissue are 
properly fixed in the standard solution (4 per cent, solution 
of formaldehyde gas) in four days. A whole brain will be 
so hardened in ten days to two weeks that thin serial sec- 
tions can be made through it without fear of the slices alter- 
ing their shape in the least. The process could undoubtedly 
be hastened by injecting the arteries. 

It must be borne in mind, however, that for most purposes 
formaldehyde must be followed by other reagents before the 
structures and their chemical properties preserved by it are 
properly fixed so that they will not be altered when trans- 
ferred to alcohol. In other words, formaldehyde may be 
looked upon as a very quick preliminary fixing reagent. 
The hardening of brains entire in it is not recommended, 
except in certain cases — for instance, of cysts, hemorrhages, 
or occasionally of tumors — where the gross lesions and the 
tracts or structures affected by them are of more importance 
than the finer histological changes. For the proper preserva- 
tion of ganglion-cells and of neuroglia-fibers very small 
pieces must be taken and fixed by the special methods 



HISTOLOGICAL METHODS. 305 

given; but if the main object is to trace system-degenera- 
tions, much larger pieces, or even the whole brain, may be 
taken, because the myelin-sheaths change comparativly very 
slowly after death. 

The stains for the central nervous system may be divided 
into two classes, general and differential. For nearly all of 
them preliminary fixation in formaldehyde is advisable or 
possible. This renders the immediate preservation of nerv- 
ous tissue very simple, and at the same time allows a variety 
of mordanting and staining methods to be used later. 

The staining of the various histological elements of the 
central nervous system and the fixing reagents best suited 
for each of them will be considered under the following 
headings : 

General Stains. 

{Protoplasmic granules ; 
Dendritic and axis-cylinder processes ; 
Axis-cylinders and their terminal processes. 
Stains for the myelin-sheath. 
Stains for the neuroglia-fibers. 

General Stains. — General stains include the ordinary 
nuclear stains, with or without a contrast-stain, and certain 
diffuse single or combined stains which color the nuclei, the 
cell-protoplasm, including to a varying extent the dendritic 
processes of the ganglion-cells, the axis-cylinders, and the 
neuroglia-fibers. The different stains vary somewhat in 
regard to the structures which they bring out most promi- 
nently. 

The best fixation for the general stains is, on the whole, 
that used for mordanting the myelin-sheaths ; in other words, 
formaldehyde combined with or followed by a chrome salt 
(see page 316). Occasionally the fixatives employed for 
other tissues are indicated. Alum-hematoxylin, followed by 
eosin, is always a useful stain. The eosin if deep enough 
brings out fairly well both the dendrites and the axis- 
cylinders. The basic aniline dyes, especially methylene-blue, 
find their greatest use in Nissl's method of staining the 
protoplasmic granules of the ganglion-cells. 
20 



306 PATHOLOGICAL TECHNIQUE. 

The various carmine solutions, particularly neutral, 
ammonia, and picro-carmine, have long been the favorite 
diffuse stains for the central nervous system, but the un- 
certainty of their action and the difficulty of always getting 
a good staining solution has gradually led to the introduc- 
tion of more reliable methods. Of these the simplest, quick- 
est, and in many ways the most generally useful is 

A. Van Gieson's Picric-acid and Acid-fuchsin Stain. 
- — Although it may be made up in the general way originally 
recommended, the following exact proportions, given by 
Freeborn, for staining nervous tissues will be found gener- 
ally preferable : 

I per cent, aqueous solution of acid fuchsin, 15 c.c. ; 
Saturated aqueous solution of picric acid, 50 " 
Water, 50 " 

1. Stain sections first rather deeply in alum-hematoxylin. 

2. Wash in water. 

3. Stain in above solution three to five minutes. 

4. Dehydrate in alcohol. 

5. Oil, Canada balsam. 

The nuclei appear bluish red, the ganglion-cells and pro- 
cesses red, the axis-cylinders brownish-red, the myelin- 
sheaths yellow, the neuroglia-fibers red. 

B. Phosphotungstic-acid hematoxylin (see page 243) 
will be found of much value as a general stain for the central 
nervous system if employed in the manner recommended 
for neuroglia-fibers after fixation by the method there given, 
because a greater differentiation of the various tissue-ele- 
ments is obtained than by any other method. Preliminary 
staining in Van Gieson's mixture is often an advantage. 

C. Phosphomolybdic-acid Hematoxylin (see page 243). 
— 1. Stain sections twenty minutes to one hour. 

2. Wash out in two or three changes of 50 per cent, 
alcohol until the celloidin becomes completely decolorized 
(about five minutes). 

3. Dehydrate in 95 per cent, alcohol. 

4. Oil, Canada balsam. 



HISTOLOGICAL METHODS. 307 

The ganglion-cells are often over-stained, especially if the 
tissue has been hardened but recently. The method is 
particularly good for bringing out the axis-cylinders and the 
neuroglia-fibers. 

D. Nigrosin. — 1. Stain sections in a concentrated aqueous 
solution of nigrosin five to ten minutes. 

2. Decolorize and dehydrate in weak, then in strong, 
alcohol. 

3. Oil, Canada balsam. 

The stain is not very sharp, but is simple and useful, par- 
ticularly for low-power observation. 

Stains for Ganglion- cells ; Protoplasmic Granules. 
— A. Nissl's Latest Improved Method. — 1. Carefully 
harden pieces of tissue not over 1 to 1.2 cm. in diameter in 
96 per cent, alcohol. 

2. Cut sections without imbedding, as follows : Remove 
excess of alcohol from tissue with filter-paper ; dip base of 
specimen in thick celloidin ; mount on block ; harden in 96 
per cent, alcohol. Moisten knife with 96 per cent, alcohol. 
Sections should always be under t J-q mm. in thickness. 
Preserve sections in 96 per cent, alcohol. 

3. Stain the sections in the following solution heated over 
a flame until it bubbles noisily (6o°-yo° C.) : 

Methylene-blue, B patent, 3.75 ; 

Venetian soap, 1.75 ; 

Distilled water, 1000. 

4. Wash out in — 

Aniline oil, 10 parts; 

96 per cent, alcohol, 90 " 

until the color is no longer given off in coarse clouds. 

5. Transfer section to slide; dry with filter-paper and 
cover with oil of cajuput. 

6. Blot with filter-paper, and then wash with a few drops 
of benzine. 

7. Add a few drops of benzine-colophonium (made by 



308 PATHOLOGICAL TECHNIQUE. 

dissolving colophonium in benzine for twenty-four hours and 
then decanting). 

8. Pass slide through flame to drive off the benzine, which 
will inflame, but if blown out immediately the specimen will 
not be injured. Repeat the process until all the benzine is 
driven off. 

9. Cover-slip. Warm the slide, so that the colophonium 
will spread out evenly between the cover-slip and the slide. 

The specimen is now mounted in a medium in which dif- 
fusion of color cannot take place, so that the stain is practi- 
cally permanent. The best results are obtained with tissues 
which have not been hardened in alcohol over one to four 
days. Contact with water, weak alcohol, and ether must be 
avoided. 

B. Lenhossek's Method for Gang-lion-cells. — The fol- 
lowing method will be found simpler, but the specimens are 
not permanent : 

1. Harden sections in 90 per cent, alcohol, then in 96 per 
cent., or in formaldehyde followed by alcohol. Do not keep 
the tissues too long in alcohol. 

2. Imbed sections in celloidin or paraffin, or cut without 
imbedding, as in Nissl's method. 

3. Stain sections in a completely saturated solution of 
thionin for five minutes. 

4. Wash for a few seconds in water. 

5. Differentiate in aniline, 1 part ; 
Absolute alcohol, 9 parts. 

Do not decolorize too long. 

6. Clear in oleum cajuputi. 

7. Xylol. 

8. Canada balsam. 

The granulations can be shown by other stains, such as 
safranin, fuchsin, dahlia, alum-hematoxylin. 

Ganglion-cells ; Dendritic and Axis-cylinder Pro- 
cesses. — Golgi's Methods. — Golgi's methods, although of 
the greatest value in the study of the normal histology of 
the central nervous system, are of very little use in the study 
of its pathology. The reason of this is the very peculiarity 



HISTOLOGICAL METHODS. 309 

that makes the method of value in normal histology — 
namely, that it picks out here and there a cell and stains it 
with all its wealth of processes more or less completely, 
while the neighboring cells are left colorless. If all of the 
cells and their processes were stained, the picture presented 
would be a confused mass. In pathological histology, where 
the presence or absence of certain cells or processes is of 
paramount importance, it is of primary necessity that every 
cell within a given area shall be perfectly stained. 

Golgi introduced three different methods of obtaining the 
stain now called after his name. They are spoken of as the 
slow, the mixed, and the short methods. Golgi himself 
employed principally the first two methods, and they are 
still used for the study of the developed brain and cord. 

The quick method exclusively has been used by Ramon y 
Cajal and other recent investigators for the study of em- 
bryonic nervous tissue. 

The following points are to be borne in mind : The tissue 
should be as fresh as possible, and should be cut into small 
pieces, not over 1 to \\ cm. thick — for the quick method 
even thinner. With the corrosive-sublimate method, how- 
ever, larger pieces can be used. 

Large quantities of the solutions should be used — at least 
ten times the volume of the specimen It is best to keep 
the specimens in the solution in the dark, especially in using 
the corrosive-sublimate method. 

Golgi' s Slow Method. — 1. Harden the tissues in a 2 per 
cent, solution of bichromate of potassium two to six weeks. 
In summer fifteen to twenty days are sufficient ; in winter, 
unless the temperature is kept at 25 ° C, one to one and a 
half months will be required. Keep the specimens in the 
dark. Large amounts of the solution should be used, and 
it should be frequently changed, especially during the first 
week. 

2. Transfer either to (a) a -f per cent, solution of nitrate 
of silver for twenty-four to forty-eight hours ; a longer time 
will do no harm ; or to (b) a J per cent, solution of corrosive 
sublimate — small pieces eight to ten days, large pieces two 



310 PATHOLOGICAL TECHNIQUE. 

months or more. Change the solution frequently during the 
first few days ; later only when the solution gets yellow. 

This second procedure is recommended for larger pieces 
of tissue than can properly be impregnated by {a). 

Golgi's Mixed Method. — i. Harden small pieces of tissue 
for three to five days or longer in a 2 per cent, solution of 
bichromate of potassium at 25 ° C, in the dark. 

2. Transfix to a mixture of — 

1 per cent, solution of osmic acid, 2 parts ; 

2 per cent, solution of bichromate of potas- 

sium, 8 " 

for three to eight days. 

3. Place in a f per cent, solution of nitrate of silver for 
twenty-four to forty-eight hours. 

Golgi's Quick Method. — 1. Small pieces of fresh tissue 
are placed directly in the following solution : 

I per cent, solution of osmic acid, 1 part ; 

3.5 per cent, solution of bichromate of potassium, 4 parts, 
for several days (three to eight). 

2. They are then transferred to a large amount of a f per 
cent, solution of nitrate of silver for one, two, or six days. 

The length of time the tissues should remain in the 
osmic-acid and bichromate-of-potassium solution depends on 
what elements it is desired to impregnate. In the human 
cord the time is in general the following : 

1. Neuroglia, 2-3 days ; 

2. Nerve-cells, 3-5 " 

3. Nerve-fibers and collaterals, 5-7 " 

The further treatment of the tissues impregnated by these 
methods is as follows : Alcohol must be avoided as much as 
possible. The tissues are usually firm enough to cut after 
the impregnation ; if not, place in absolute alcohol for fifteen 
to thirty minutes. The sections should be rather thick, -^V 
to -^ mm. They may be made free hand with a razor or in 
the microtome. For either method the tissues can be held 
between pieces of elder-pith, or may be quickly imbedded in 



HISTOLOGICAL METHODS. 3II 

celloidin by dehydrating for a few minutes in absolute alco- 
hol and then placing in a thick solution for five minutes. 
From the celloidin they are mounted in elder-pith or on 
blocks, and placed for a short time in 80 per cent, alcohol to 
harden. 

Treatment of Sections. — r. Dehydrate quickly in alcohol. 

2. Clear in oil of cloves or bergamot. 

3. Wash off with xylol. 

4. Mount without a cover-glass in xylol damar, and dry- 
quickly at 40 C. 

The mounted sections must be protected from the light 
and from dust as much as possible. Cajal has modified 
Golgi's quick method by repeating the steps (Cajal's so- 
called double method) so as to get a more perfect impregna- 
tion. The same osmic-acid and bichromate-of-potassium 
solution may be used over again, or a fresh solution, con- 
taining about one-half as much osmic acid, is made up fresh. 
The silver solution should be taken fresh each time. Len- 
hossek, Weigert, and others have obtained very good Golgi 
preparations with tissues first fixed in formaldehyde. 

Of the various methods proposed for fixing the Golgi 
stains so that contrast-stains could be used with them and 
the specimens protected by cover-slips, the simplest and 
most practical seems to be that advocated by Kallius. 

The Method of Kallius for Fixing Golgi Stains.— The 
method depends on the employment of a photographic 
developer to reduce the bichromate of silver to metallic 
silver. 

1. Place sections for several minutes in a solution com- 
posed of 1 part of the following developer : 

Hydrochinon, 1 ; 

Sulphite of sodium, 8 ; 

Carbonate of potassium, 1.5 ; 

Water, 575, 

plus one-third to one-half as much absolute alcohol until, 
the sections become gray to black in color. If too much 
alcohol is added, the carbonate of potassium will be pre- 



312 PATHOLOGICAL TECHNIQUE, 

cipitated, but will redissolve on the addition of a little more 
developer. 

2. 70 per cent, alcohol for ten to fifteen minutes. 

3. Hyposulphite of sodium (20 per cent, aqueous solu- 
tion). 

4. Wash thoroughly in a large amount of water for twenty- 
four hours. 

5. Alcohol, oil, Canada balsam ; cover-glass. 

Cox's Modification of Golgl's Corrosive-sublimate 
Method. — The same black pictures are obtained by this 
method as by Golgi's, but with this difference, that nearly all 
of the cells in the section are impregnated. This is an ad- 
vantage when the topographical arrangement of the cell- 
layers is desired, but a disadvantage when it comes to the 
study of individual cells, because on account of the luxuri- 
ance of the impregnation such a study is rendered impos- 
sible. Small pieces of nervous tissue are placed in the fol- 
lowing solution : 

Bichromate-of-potassium 5 per cent, solution, 20 ; 

Corrosive-sublimate 5 per cent, solution, 20 ; 

Distilled water, 30-40; 

Simple chromate-of-potassium 5 per cent, solution, 16. 

The time required for impregnation is a month in summer 
and two to three months in winter. The after-treatment is 
the same as for Golgi preparations. 

Axis-cylinders and their Terminal Processes. — 
The three methods most in use for the study of central and 
peripheral nerve-fibers and their terminations are the gold, 
the Golgi, and the methylene-blue method. All three may 
give beautiful results, but, as a rule, they are very unreliable. 
Their use is confined almost wholly to the study of normal 
tissues. 

Gold Stain for Nerve-fibers. — For the application of the 
gold method to fresh tissues see p. 260. 

Various attempts have been made to devise a reliable 
method of employing chlorid of gold for staining nerve- 
fibers in sections of hardened tissues. The results have not 



HISTOLOGICAL METHODS. 313 

been altogether successful. The best results can probably 
be obtained by — 

A. Gerlach's Method. — I. Harden tissues in a 1-2 per cent, 
solution of bichromate of ammonium for one to three weeks ; 
cut sections without passing through alcohol, which must be 
avoided. 

2. Place the sections in a very dilute solution (yJ-q- per 
cent.) of the double chlorid of gold and potassium very 
slightly acidulated with hydrochloric acid, for ten to twelve 
hours, until they become slightly violet in color. 

3. Wash in a solution of hydrochloric acid 1, to water 
2000-3000. 

4. Place for ten minutes in a ^ per cent, solution of hy- 
drochloric acid in 60 per cent, alcohol. 

5. Absolute alcohol, oil of cloves, Canada balsam. 
Another method frequently recommended is the following : 

B. Freud s Gold Stain for Nerve-fibers. — 1. Harden tissues 
in Erlicki's or Muller's fluid, followed by alcohol. Imbed in 
celloidin. 

2. Stain sections three to five hours in 1 per cent, solution 
of chlorid of gold, and 95 per cent, alcohol, equal parts. 

3. Wash in water. 

4. Reduce in — 

Caustic soda, 1 ; 

Distilled water, 6, 

for two to three minutes. 

5. Wash in water. 

6. Place for five to fifteen minutes in a 10 per cent, solu- 
tion of iodid of potassium. 

7. Wash in water. 

8. Alcohol, oil, Canada balsam. 

C. Stroebe's Aniline-blue Stain for Nerve-fibers in Hard- 
ened Sections. — Harden tissues in Muller's fluid. 1. Stain 
one-half to one hour in a saturated aqueous solution of ani- 
line-blue. 

2. Wash in water. 

3. Transfer to a small dish of alcohol to which are added 



3 14 PATHOLOGICAL TECHNIQUE. 

20 to 30 drops of a 1 per cent, alcoholic solution of caustic 
potash (caustic potash 1 to alcohol 100 : let the mixture 
stand for twenty-four hours ; then filter). In one to several 
minutes the sections become bright brownish-red and trans- 
parent. 

4. Transfer to distilled water for five minutes. The sec- 
tion becomes bright blue again. 

5. Stain in a half-saturated aqueous solution of safranin 
one-quarter to one-half hour long. 

6. Wash out and dehydrate in absolute alcohol. 

7. Xylol, Canada balsam. 

D. Odorid-of-iron and dinitroresorcin method Tor the study 
of degenerated peripheral nerves : 

1. Place fresh pieces of peripheral nerves for several days 
in a solution of — 

Chlorid of iron, 1 part ; 

Distilled water, 4 parts. 

2. Wash out thoroughly in water. 

3. Transfer to a saturated solution of dinitroresorcin in 75 
per cent, alcohol for several weeks. 

4. Wash, dehydrate, imbed, etc. 

A permanent green color is formed which stains the nerves 
green and brings out the green axis-cylinders very sharply. 

The stain will succeed with preparations which have been 
hardened in Flemming's solution or Miiller's fluid. 

Golgi's methods are sometimes employed for the study of 
the terminal processes of nerve-fibers (for directions see 

p. 308). 

Methylene-blue Stain for Nerve-fibers. — The methylene- 
blue method is due to Ehrlich. Many modifications of the 
original procedure have been suggested with a view to mak- 
ing the results surer or the specimens more permanent. 
Tissues can be stained either by injection or by immersion. 

The methylene-blue used should be Grubler's " rectified 
methylene-blue for vital injection." 

For injection in the blood- or lymph-vessels of live or 
dead animals a 1 to 4 per cent, solution in normal salt solu- 



HISTOLOGICAL METHODS. 315 

tion is recommended. The injected organs are exposed to 
the air until a bluish tint is visible. As soon as the greatest 
intensity of stain is reached (five minutes to two hours) the 
color in the preparation is fixed by placing small bits of the 
tissue in a freshly-filtered, cold, saturated, aqueous solution 
of picrate of ammonium, or, better still, in the solution given 
below, recommended by Bethe. 

Very small or thin pieces of tissue intended for staining by 
immersion (the method employed for human tissues) are 
placed in a very dilute solution ( ^ ^ per cent.) of methyl- 
ene-blue in normal salt solution. Lavdowski recommends 
very highly a solution of methylene-blue in egg-albumin, 
either alone or combined with chlorid of sodium or ammo- 
nium. The white of egg is freed from the thicker portions or 
filtered. When the experiment is to last some time, add to 
the egg-albumin an equal part of a J per cent, solution of 
chlorid of sodium or of a J per cent, solution of chlorid of 
ammonium. The tissue, protected by a large dish, is exposed 
to the air for fifteen minutes to twelve hours, until the maxi- 
mum stain is obtained. 

The stain may then be fixed by the method already given, 
or, better still, in the following manner : 

Bethe's Metliod of Fixing Methylene-blue Stains of Nerve- 
fibers. — 1. Wash off excess of color with normal salt solu- 
tion. 

2. Place in — 



Molybdate of ammonium, 


1 gr.; 


Distilled water, 


10 c.c. ; 


Peroxid of hydrogen, 


1 " 


Hydrochloric acid, 


1 drop 



A precipitate forms on making up the solution, but disap- 
pears on shaking. The solution will keep eight days, but is 
best made up fresh each time. It should be used as cold as 
possible, preferably surrounded by a mixture of ice and salt. 
Leave the tissue in the cold solution for from two to five 
hours, and then for a while longer at the room-temperature. 
3. Wash one half to two hours in running water. 



316 PATHOLOGICAL TECHNIQUE. 

4. Dehydrate and harden as quickly as possible (not over 
twelve to twenty-four hours) in cold absolute alcohol. (The 
color is soluble in warm alcohol.) 

5. Clear in xylol. 

6. Imbed in paraffin. 

The sections may be mounted directly or brought into 
water and stained with alum-cochineal for contrast. If a little 
osmic acid be added to the fixing solution after the speci- 
mens have been in it for a while, a more permanent methyl- 
ene-blue stain is obtained. 

Stains for the Myelin-sheath. — The myelin-sheath 
of nerve-fibers is a form of fat, and like it possesses the 
property of reducing osmic acid, by means of which a selec- 
tive sheath stain can be obtained. Unfortunately, however, 
the osmic acid penetrates to but a very slight depth. 

The differential hematoxylin stain, originated by Weigert, 
and ordinarily used, depends on some chemical reaction 
which takes place between the myelin and a chrome salt, in 
consequence of which the myelin is fixed so that it will not 
later be dissolved out by alcohol or ether, and at the same 
time is so mordanted that it can be deeply stained with 
hematoxylin, to which it clings when treated with certain 
decolorizers. This reaction between the myelin and the 
chrome salt takes place very slowly at the ordinary temper- 
ature ; six weeks to several months are usually required. 
Weigert has lately published a method depending on the 
interaction of two chrome salts in the same solution, in 
consequence of which the time needed for this reaction or 
mordanting is reduced to four days. The solution may be 
used alone, but is best combined with formaldehyde or used 
after it. Large masses of nervous tissue, like the medulla 
and pons or the basal ganglia, should be hardened in formal- 
dehyde for one to three weeks, and then cut into parallel 
slices not over 1 cm. thick for mordanting by Weigert's 
quick method. 

A. "Weigert's Quick Method for Mordanting" Myelin- 
sheaths. — 1, Fix the tissues in a 4 per cent, solution of 
formaldeyhde (10 per cent, solution of formaline) for four 



HISTOLOGICAL METHODS. 317 

days to several weeks. Four days are sufficient for pieces 
not over 1 cm. thick. The solution, of which several times 
the volume of the specimen must be taken, is changed at 
the end of twenty-four hours. The tissue may remain in- 
definitely in it. 

2. Mordant the myelin-sheaths in the following solution ; 

Bichromate of potassium, 5 ; 

Chrome alum, 2 ; 

Water, 100, 

for four to eight days. The tissues should not exceed 1 cm. 
in thickness, and should not be left in the solution longer 
than eight days, because they will become brittle. 

3. Transfer directly to alcohol (80 per cent.), and keep in 
the dark until wanted for imbedding, changing the alcohol 
occasionally as it becomes colored. 

Steps 1 and 2 may be combined by adding 4 per cent, of 
formaldehyde to the mordanting solution and placing fresh 
tissues directly in the mixture. In place of Weigert's quick 
mordant, Muller's fluid or a 5 per cent, solution of bi- 
chromate of potassium may be used after fixation in formal- 
dehyde, but the process of mordanting will require as long 
(six to eight weeks) as though the tissues had originally 
been placed in them. 

Weigert's quick mordant can be highly recommended, 
both on account of the short time it requires and because 
the stains obtained after it are very satisfactory. The great- 
est objection to it is that exposure for over four days to the 
mordant renders the cerebral cortex very brittle. 

Weigerts Myelin-sheath Stain. — 1. Fix and mordant the 
tissues in one of the ways already described, or, if preferred, 
in Muller's fluid. 

2. Dehydrate in alcohol without washing out in water. 

3. Imbed in celloidin. 

4. Place sections for twenty-four hours in the following 
solution, which Weigert now recommends in place of the 
simple saturated solution of acetate of copper formerly ad- 
vised : 



318 PATHOLOGICAL TECHNIQUE. 

Acetate of copper, 5. 

Acetic acid, 36 per cent, solution, 5. 

Chrome alum, 2.5 

Water, ad 100. 

(For method of preparation see page 323). 

5. Stain fifteen minutes to twenty-four hours in — 

Hematoxylin, I ; 

Absolute alcohol, 10; 
Saturated aqueous solution of carbonate of 

lithium, 7 ; 

Water, 90. 

Keep a 10 per cent, solution of hematoxylin in alcohol on 
hand, so that it will be ripe. Combine with the carbonate 
of lithium and the water at the time of using. 

6. Wash thoroughly in water. 

7. Decolorize in — 

Borax, 4 ; 

Ferrocyanide of potassium, 5 ; 

Water, 200, 
until the gray substance is distinctly yellow. 

8. Wash thoroughly in water. 

9. Dehydrate in 95 per cent, alcohol. 

10. Clear in aniline oil 2, xylol 1. 

11. Canada balsam. 

Weigert has given up his direct myelin-sheath stain be- 
cause the preparations do not keep. 

B. Pal's Modification of Weigert' s Myelin-sheath Stain. 
— 1. Fixation as for Weigert's method. 

2. Place sections for several hours in a J per cent, aqueous 
solution of chromic acid, or for a longer time in a 2-3 per 
cent, solution of bichromate of potassium. This step is 
often omitted, especially when the tissues have been but 
recently mordanted. 

3. Transfer sections to Weigert's hematoxylin solution 
for twenty-four to forty-eight hours (if necessary for an 
hour in the incubator at 37 C). 



HISTOLOGICAL METHODS. 319 

4. Wash in water plus 1 to 3 per cent, of a saturated 
aqueous solution of carbonate of lithium until the sections 
appear of a uniform deep-blue color. 

5. Differentiate for twenty seconds to five minutes in a \ 
per cent, aqueous solution of permanganate of potassium 
until the gray matter looks brownish-yellow. 

6. Transfer to the following solution : 

Oxalic acid, 1 ; 

Sulphite of potassium, 1 ; 

Water, 200, 

for a few seconds until the gray matter is colorless or 
nearly so. 

7. Wash thoroughly in water. 

8. Dehydrate in 95 per cent, alcohol. 

9. Oil, Canada balsam. 

Steps 5 and 6 sometimes have to be repeated when the 
differentiation has not been complete. 

Of all the numerous modifications of Weigert's original 
myelin-sheath stain, the only one that has found general 
acceptance is Pal's. It has the following advantages : It 
gives very clear pictures ; everything except the sheaths is 
completely decolorized, so that contrast-stains are possible ; 
it is more successful with thick sections than Weigert's 
method ; the separate steps are quicker. On the other 
hand, the danger of decolorizing the sheaths of the finer 
fibers is greater. 

C. Exner's Method of Demonstrating- Myelin-sheaths. 
— The tissue should be obtained as soon as possible after 
death, although the method will succeed with tissues even 
over twelve hours old. 

1. Place pieces of brain or cord not over \ cm. thick in a 
I per cent, aqueous solution of osmic acid, using at least ten 
times as much fluid as the volume of the specimen. 

2. Change the osmic-acid solution on the second day. 

3. After five or six days wash thoroughly in water. 

4. Dehydrate, imbed, etc, 



320 PATHOLOGICAL TECHNIQUE. 

5. Examine sections in glycerin rendered slightly ammoni- 
acal. 

The myelin-sheaths appear gray to black. The prepara- 
tions are not permanent. 

This procedure has been almost entirely replaced by Wei- 
gert's method, which has numerous advantages. Lately, 
however, it has been brought forward again by Heller, who 
uses a photographic developer to reduce the osmic acid and 
to make possible permanent mounts. He has lately pub- 
lished the following method for sections, but it cannot be 
unconditionally recommended : 

D. Heller's Method for Staining" Myelin-sheaths with 
Osmic Acid. — 1. Harden as for the Weigert method (Heller 
used Muller's fluid). 

2. Imbed in celloidin. 

3. Place sections in a 1 per cent, aqueous solution of os- 
mic acid for ten minutes in thermostat or for half an hour at 
room-temperature. 

4. Wash in water. 

5. Reduce in the following developer: 

Sulphate of sodium, 125 ; 

Carbonate of sodium, 70 ; 

Water, 500; 

Pyrogallic acid, 15. 

6. Wash in water. 

7. Differentiate in an aqueous solution of permanganate 
of potassium, \ per cent, or less. 

8. Remove the brown of the permanganate of potassium 
in a 1 per cent, aqueous solution of oxalic acid. 

9. Wash in water. 

10. Alcohol, oil, Canada balsam. 

By a modification of Heller's method Robertson claims to 
get better results. 

1. Harden in Weigert's chrome-alum-copper solution plus 
4 per cent, of formaldehyde ; in other words, use the mor- 
dant for neuroglia-fibers (page 323) eight to ten days. 



HISTOLOGICAL METHODS. 32 1 

2. Wash off in water. 

3. Alcohol ; imbed in celloidin. 

4. Stain sections in a 1 per cent, solution of osmic acid 
half an hour in the dark. 

5. Place in a 5 per cent, aqueous solution of pyrogallic 
acid for half an hour. 

6. Differentiate in a \ per cent, aqueous solution of per- 
manganate of potassium one to four minutes. 

7. Remove brown color in 1 per cent, oxalic acid three to 
five minutes. 

8. Alcohol, oil, balsam. 

It is important to wash carefully in water between each of 
the staining steps. 

Stains for Neuroglia-fibers. — It is possible to obtain 
a differential stain of the neuroglia-fibers in man by three 
different methods, provided the first two of the following 
steps are complied with : 

1. The tissue must be as fresh as possible. The best re- 
sults are obtained with tissues placed in the fixing solution 
within one hour after death. After four to six hours the re- 
sults are only fair ; after twenty-four hours they are practi- 
cally nil. The chemical property in the neuroglia-fibers on 
which the differential stain depends has undergone some 
chemical change or has disappeared. It is retained longest 
where the fibers are most numerous, as about the central 
canal. 

2. Formaldehyde must be used as the fixative, either alone 
or combined with certain other reagents mentioned below. 
No other fixatives yet known penetrate so rapidly and pre- 
serve so well the chemical properties of the neuroglia-fibers. 
According to Weigert, who first fully recognized the value 
of formaldehyde in preserving neuroglia-fibers, the best 
strength to use is a 4 per cent, solution {i. e. a 10 per cent, 
solution of formaline, etc.). The pieces of tissue in which it 
is desired to stain the neuroglia-fibers must be cut very thin, 
never over \ cm. thick, and preferably thinner. With thicker 
pieces only the surface sections are of any value. 

3. The tissues after fixation must be mordanted, so as to 

21 



322 PATHOLOGICAL TECHNIQUE. 

render the staining more intense ; without mordanting only 
a few of the fibers will stain. 

4. Staining may be performed by modifications of Wei- 
gert's fibrin-stain or with phosphotungstic-acid hematoxylin. 

The methods of staining neuroglia-fibers are given in the 
order of their publication. The second method (Weigert's) 
gives a more intense stain than the first, but has the draw- 
back of staining degenerated nerve-fibers. The third method 
is not so selective as the other two, but is useful because it 
brings out all the tissue-elements. All of the methods are 
unsuccessful with the neuroglia-fibers of animals other than 
man. 

Differential Stain for Neuroglia-fibers (Mallory). — 1. Fix 
in a 4 per cent, aqueous solution of formaldehyde four days 
or more. 

2. Place in a saturated aqueous solution of picric acid four 
to eight days. 

Steps 1 and 2 may be combined by adding 10 parts of the 
40 per cent, formaldehyde solution to 90 parts of the satu- 
rated aqueous solution of picric acid. 

3. Transfer to a 5 per cent, aqueous solution of bichro- 
mate of ammonium for four to six days in the incubator at 
37 C, or for three to four weeks at room-temperature. 
Change the solution on the second day. 

4. Place directly in alcohol. 

5. Imbed in celloidin. 

6. Fasten sections to slide by means of ether-vapor. 

7. Stain in aniline-gentian-violet fifteen to twenty minutes. 

8. Wash off with normal salt solution. 

9. Iodin solution, 1 : 2 : 100, for one minute, or a stronger 
solution for a few seconds. 

10. Wash off with water. 

11. Dry with filter-paper. 

12. Decolorize in equal parts of aniline and xylol. 

13. Wash off thoroughly with xylol. 

14. Xylol balsam. 

The neuroglia-fibers, fibrin, nuclei, and, to some extent, 
the red blood-globules, are stained blue. The other tissue- 



HISTOLOGICAL METHODS. 323 

elements are colorless. By very faintly tinting the aniline- 
and-xylol mixture with fuchsin, which is readily soluble in 
aniline, the other tissue-elements are easily brought out, but 
the finer neuroglia-fibers are likely to lose their blue color. 

Weigert's Method for Neuroglia-fibers. — A. Fix thin 
pieces of tissue, not over \ cm. thick, in a 4 per cent, solu- 
tion of formaldehyde for at least four days. 

B. Mordant in the following solution for four to five days 
in the incubator or for eight days at room-temperature : 

Acetate of copper, 5 gr. ; 

Acetic acid, 36 per cent, solution, 5 c.c. ; 

Chrome alum, 2.5 gr. ; 

Water, ad 100 c.c. 

Boil the chrome alum in a covered dish (it turns green in 
color), turn out the gas, add the acetic acid and then the 
acetate of copper ; stir until the latter is dissolved, then 
cool. The solution remains clear. If the directions and 
order of procedure are not followed exactly, a green pre- 
cipitate will form. 

(Steps 1 and 2 -may be combined by adding 4 per cent, of 
formaldehyde to the above solution ; change on the second 
day ; harden eight days.) 

C. Wash off in water ; dehydrate in alcohol ; imbed in 
celloidin. 

D. Reduction of copper salt in sections : 

1. Place the sections, which must not be over .02 mm. 
thick, in a \ per cent, aqueous solution of permanganate of 
potassium for ten minutes. 

2. Wash off with water. 

3. Decolorize and reduce for two to four hours in the fol- 
lowing solution, carefully filtrated : 



Chromogen, 


5 g^ 


Formic acid (sp. gr. 1.20), 


5 c.c. 


Water, 


ad 100 " 



to 90 c.c. of which are added just before using 10 c.c. of a 
10 per cent, solution of sulphite of sodium. 



324 PATHOLOGICAL TECHNIQUE. 

The sections lose their color in a few minutes, but are best 
kept in the solution as long as above directed. 

The sections can now be stained in the manner to be de- 
scribed, but the color of the fibers will be more intense if 
the following steps are added, and a slight yellowish con- 
trast-stain is obtained for the ganglion and ependymal cells 
and for the larger nerve-fibers. 

E. Further reduction of copper salt : 

1. Wash twice in water. 

2. Place sections in a carefully filtered saturated (5 per 
cent.) aqueous solution of chromogen over night. 

3. Wash in water. 

4. The sections are now ready for staining or may be pre- 
served until wanted in — 

80 per cent, alcohol, 90 c.c. 

5 per cent, oxalic acid, 10 " 

F. Staining of neuroglia-fibers : 

1. Lift section from large dish of water on slide freshly 
cleaned with alcohol ; blot with filter-paper (method recom- 
mended by Weigert for attaching sections to slide). 

2. Stain in the following mixture : 

Saturated solution of methyl-violet in 

70-80 per cent, alcohol, 100 c.c. ; 

(saturated with aid of heat ; decanted 
when cold). 

5 per cent, aqueous solution of oxalic 

acid, 5 " 

The oxalic acid is added to render the preparations more 
lasting. The staining is practically instantaneous. 

3. Wash off with normal salt solution. 

4. Iodin solution : 5 per cent, iodid-of-potassium solution 
saturated with iodin. It is simply poured on and then off, 
as the reaction is instantaneous. 

5. Wash off with water and blot with filter-paper. 

6. Decolorize thoroughly in equal parts of xylol and 
aniline oil. 



HISTOLOGICAL METHODS. 325 

7. Wash repeatedly with xylol or the stain will not keep. 

8. Canada balsam. 

The sections keep better if exposed for from two to five 
days to diffuse light before being put away. 

Differential Stain of Neuroglia-fibers by means of 
Phosphotungstic-acid Hematoxylin (Mallory). — 1. Fix and 
mordant tissues in exactly the same way as in the first 
method given for neuroglia-fibers — viz. : 

(a) Fix in 4 per cent, aqueous solution of formaldehyde 

four days. 

(b) Saturated aqueous solution of picric acid four days. 

(c) 5 per cent, aqueous solution of bichromate of 

ammonium four to six days in incubator or three 
to four weeks at room-temperature. 

(d) Alcohol, celloidin, etc. 

2. Stain sections in phosphotungstic-acid hematoxylin 
four to twenty-four hours. 

3. Wash in water. 

4. Alcohol. 

5. Oleum origani cretici. 

6. Xylol balsam. . 

Neuroglia-fibers, if properly preserved, deep blue ; nuclei, 
blue; connective tissue, deep pink; axis-cylinders, light 
pink ; myelin-sheaths, yellow if thoroughly mordanted with 
the bichromate of ammonium, otherwise with prolonged 
staining they may take on a greenish-blue color : proto- 
plasm of ganglion-cells and the dendritic processes, purplish 
or bluish gray. It will sometimes be found advantageous to 
stain sections lightly in Van Gieson's mixture first, so that 
the axis-cylinders may have a deeper red stain, and the con- 
trast in color between the dendritic processes and the neurog- 
lia-fibers may be greater. 

Degenerations of the Nervous System. — The same 
methods apply to the study of degenerations in nervous tis- 
sue that apply elsewhere, except in the demonstration of 
fat. Both myelin and fat reduce osmic acid, so that the or- 
dinary test for fat in the hardened tissues fails. Marchi and 
Algeri, however, have shown that after myelin has been mor- 



326 PATHOLOGICAL TECHNIQUE. 

danted for eight days or over in Muller's fluid or other solu- 
tion of the bichromates, it loses the property of reducing the 
osmic acid, while fat retains the property unimpaired. On 
this peculiarity is based their method for differentiating fat 
from myelin. 

March! and Algeri's Method for Staining- Patty De- 
generated Myelin-sheaths of Nerve-fibers. — i. Harden in 
Muller's fluid or in formaldehyde, followed by Muller's fluid, 
for eight days to three months. 

2. Transfer tissue for five to eight days directly into the 
following solution : 

Muller's fluid, 2 parts ; 

I per cent, osmic-acid solution, I part. 

3. Wash out thoroughly in water. 

4. Dehydrate in alcohol. 

5. Imbed in celloidin. 

6. Mount in thick Canada balsam (which must not be dis- 
solved in chloroform). 



EXAMINATION OF THE BLOOD. 

The specific gravity of the blood varies but slightly and 
averages 1055. For clinical purposes the method of Ham- 
merschlag is the best for estimating the specific gravity. The 
method depends upon the physical law that a body which re- 
mains suspended in a fluid must have the same specific grav- 
ity as that fluid. The fluid selected is a mixture of chloro- 
form (specific gravity 1526) and benzol (specific gravity 0.889). 
A drop of blood does not mix with either fluid. 

A small test-tube holding about 10 c.c. is half filled with 
a mixture of benzol and chloroform. This mixture should 
have the specific gravity of from 1050 to 1060. A drop of 
freshly-drawn blood is allowed to fall into this mixture, care 
being exercised that the drop falls directly into the fluid. 
Chloroform or benzol is added according as the drop of blood 
sinks to the bottom or floats on the surface of the fluid. It 



HISTOLOGICAL METHODS. 327 

is necessary in adding either of the fluids to thoroughly mix 
them by gentle rotating movements without breaking the 
blood-drop. If the drop floats on the surface, it is better to 
add sufficient benzol to make it sink to the bottom, and then 
add chloroform until it becomes suspended in the fluid. 
Too large a drop of blood is liable to be broken up in mix- 
ing the fluids, and this must be avoided. When the drop re- 
mains suspended in the thoroughly mixed fluids the latter is 
filtered and the specific gravity tested. 

Apparatus Used in the Examination of the Blood. 
— An accurate examination of the blood can be made only 
by the strictest observance of cleanliness and attention to de- 
tails. It has been deemed wise, therefore, to devote the 
greater part of this article to a description of the various 
steps of the process for the benefit of those who are unfa- 
miliar with the technique. 

With this object in view it is not necessary to describe the 
numerous instruments which have been devised for examin- 
ing blood or to refer to many of the staining fluids. The 
Thoma-Zeiss hemocytometer, or blood-counting instrument 
(Fig. 100), is the one which is generally employed to count 
the red and white blood-corpuscles, and consists of a glass 
slide on which the blood-corpuscles are counted and a pi- 
pette for mixing the blood and diluting fluid. The counting 
slide has a thin square plate of glass cemented on its surface : 
a circular opening in the center of this plate is nearly filled 
by a glass disc -^ mm. thinner than the square plate which 
surrounds it. A series of horizontal and vertical lines on the 
surface of the disc divides it into squares, the sides of which 
are -fa mm. long. Additional lines placed close together 
divide this surface into quadrants. Each quadrant contains 
sixteen of the small squares. 

The pipette consists of a capillary tube which expands 
into an ovoid chamber above. The chamber contains a glass 
pearl, which assists in mixing the blood and diluting fluid. 
The capillary tube has a capacity of 1 mm. and is graduated 
to tenths. Above the ovoid chamber is a line marked 101 mm. 
A dilution of I to 100 or 1 to 200 is obtained by sucking 



328 



PA THOL O GICAL TE CHNIQ UE. 
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a 



Fig. ioo. — Thoma-Zeiss blood-counting apparatus (Limbeck) : A.melangeur; 
a, capillary tube in which the blood is taken ; b, chamber for mixing the blood 
with the diluting solution ; c, glass ball to aid in mixing the blood with the dilut- 
ing solution ; B, cross-section of the chamber in which the blood is counted ; 

C, section of the field on which the blood is counted, showing thirty-six squares ; 

D, diagram of the whole field. 



HISTOLOGICAL METHODS. 



329 



the blood up to the mark 1. or 0.5, and the diluting fluid up 
to the mark 101. 

A second pipette for counting the white corpuscles is grad- 
uated in such a way as to give a dilution of 1 to 10 or 1 to 20. 

For clinical purposes the Von Fleischl hemometer (Fig. 101) 




Fig. ioi. — Von Fleischl's hemometer : a, stand ; b, narrow wedge-shaped piece 
of colored glass fitted into a frame (c) which passes under the chamber; d, hol- 
low metal cylinder, divided into two compartments, which holds the blood and 
water; e, white plate from which the light is reflected through the chamber; 
/, screw by which the frame containing the colored glass is moved ; g, capillary 
tube to collect the blood; h, pipette for adding the water; i, opening through 
which may be seen the scale indicating percentage of hemoglobin. 



is generally used to estimate the hemoglobin. This instru- 
ment is fairly accurate, but for percentages of hemoglobin 
below 50 per cent, it is safe to allow 5 per cent, for error in 
the apparatus. The instrument consists of a metal stand (a), 
a narrow wedge-shaped piece of colored glass (b), a hollow 
metal cylinder (d), and capillary tubes (g). The metal stand 



330 PATHOLOGICAL TECHNIQUE. 

(a) is fitted with a flat stage above, in which is an aperture 
for holding the cylinder (d). On the under surface of this 
stage are two metal- rims in which the glass wedge (ft) fits. 
These rims are arranged so as to allow the glass wedge 
to move across the aperture by means of an adjustment 
screw. The glass wedge (ft) is colored red, the degree of 
color becoming more intense toward the thick end. The 
glass is held in a metal frame, on one of whose sides 
parallel with the glass there is a scale of percentages from 
o. to 1 20, corresponding to the intensity of the color in the 
glass. The metal cylinder (d) is divided into two equal com- 
partments by a thin metal partition which extends from one 
end of the cylinder to the other. One end of the cylinder 
is closed by a piece of glass. The blood is collected in the 
capillary tube (g). 

Preparation of Apparatus. — Three things are essential 
in order to make a satisfactory examination of the blood : 
the apparatus must be absolutely clean ; the various stages 
in the process must be performed rapidly, because a very 
slight coagulation of the blood will interfere with any of the 
tests ; and the work must be done accurately. 

Many of the details which follow may appear trivial to 
one who is unfamiliar with the methods employed in making 
blood-examinations. Experience will convince such an one 
to the contrary. All apparatus should be thoroughly 
cleaned and dried immediately after completing a blood-ex- 
amination. The " mixing pipette " for estimating the blood- 
corpuscles can be readily cleaned by removing the rubber 
tubing and fixing it to the other end of the pipette, or a 
double atomizer bulb, such as is used on the Paquelin cau- 
tery, may be substituted. The pipette should be cleaned 
with water, alcohol, and finally with ether, until it is dry in- 
side. If the alcohol fails to remove all of the staining fluid 
from the inside of the pipette and from the glass pearl, acid 
alcohol (hydrochloric acid 1 part, alcohol (70 per cent.) 100 
parts) may be used. This should be followed by alcohol, 
and then by ether. The blood-counting slide may be cleaned 
with water. If any of the staining fluid adheres to the slide, 



HISTOLOGICAL METHODS. 33 1 

it may be removed with alcohol. If alcohol is used to clean 
the counting slide, it must be used rapidly and the slide 
washed with water, because alcohol dissolves the cement by 
means of which the thin square of glass and the disc are 
fastened to the slide. The capillary tubes used for estimat- 
ing the hemoglobin should be cleaned in the same way as 
the " mixing pipette." It has been found that the blood fills 
the capillary tube more readily if the latter is cleansed a 
second time with water directly before making the blood- 
examination. If this is done, it is necessary to thoroughly 
dry the tube afterward. This may be accomplished by re- 
moving most of the water and drying the remaining moist- 
ure by passing the tube rapidly through an alcohol flame. 
Care must be taken to avoid breaking it. The metal 
cylinder is cleaned by unscrewing the bottom and removing 
the glass. In this way the cylinder can be easily and thor- 
oughly washed and dried. The cover-glasses should be 
kept in a solution of acid alcohol (see above). Before begin- 
ning a blood-examination a dozen or more of these cover- 
glasses should be cleaned with water, and then with alcohol, 
and dried ; then they should be passed through an alcohol 
flame and spread on a piece of paper. The cover-glasses 
should not be touched with the fingers after cleaning them, 
but should be handled with forceps. New cover-glasses are 
covered with an oily glaze which prevents the blood from 
spreading. Moisture from the fingers may alter the shape 
of the red blood-corpuscles. 

Never begin an examination of the blood until everything 
required for the entire examination is ready for use. A suf- 
ficient quantity of the diluting solutions must be poured into 
small dishes and placed, with the apparatus and cover- 
glasses, close at hand. If the preserving fluid contains a 
staining fluid, the solution must be filtered before using. 

To obtain the blood the part from which it is taken 
should be cleaned with soap and water, alcohol, and finally 
with ether, and thoroughly dried The blood is usually ob- 
tained from the lobe of the ear or from the end of the finger. 
The ear possesses distinct advantages over the end of the 



332 PATHOLOGICAL TECHNIQUE. 

finger. It is not necessary to hold the ear to prevent its 
withdrawal ; the operation is less painful, and the blood is 
obtained more easily because the epidermis is thinner. These 
advantages are especially evident in infants and young chil- 
dren. In children it is almost impossible to keep the fingers 
extended without exerting pressure. Pressure on the part 
from which the blood is withdrawn must be avoided. It has 
been ascertained that moderately firm pressure on the finger 
is capable of diminishing the number of red corpuscles in a 
cubic millimeter by increasing the quantity of serum. The 
free border of the lobe of the ear is preferable to the anterior 
surface, because the border is convex. This is of advantage 
in making cover-glass preparations from small drops of 
blood. A narrow-bladed knife, similar to a tenotomy-knife, 
makes a relatively wide and shallow opening, and is prefer- 
able to a needle. 

The hemoglobin test must be performed in a dark 
room by means of a yellow light — lamp, gas, or candle light. 
Before obtaining the blood fill one of the divisions of the 
cylinder one-fourth full with distilled water ; then partly fill 
the pipette provided for this purpose, and place it close at 
hand ready to wash out any blood which may remain in the 
capillary tube, and thus prevent coagulation. The capillary 
tube is held horizontally, and touched slightly on the side of 
a freshly drawn drop of blood. The end of the tube should 
never be dipped deeply beneath the surface of a blood-drop. 
If the tube is perfectly clean and no coagulation has occurred 
in the drop of blood, the latter will instantly fill the tube. 
Sometimes it is necessary to slightly withdraw the end of 
the tube, without, however, permitting it to entirely leave 
the surface of the blood. Observe that the tube is exactly 
filled with blood and that the ends show neither convexity 
nor concavity. Any blood adhering to the end of the tube 
or to its outer surface must be quickly wiped off. Rapidly 
submerge the tube in the water and move it quickly to and 
fro several times, and with as little delay as possible wash 
out the remaining blood by means of the pipette. Fill the 
chamber three-fourths full with water and stir briskly with 



HISTOLOGICAL METHODS. 333 

the metal handle of the capillary tube. Be careful to stir 
in the corners where the partition joins the sides. The blood 
should be equally diffused throughout the fluid when the 
mixing has been well done, and there should be no coagula 
in it. When this has been done fill the cylinder to the level 
of the diaphragm ; the other division of the cylinder is then 
filled to the level of the diaphragm with distilled water. 
The surface of the fluid in each side must be perfectly flat. 
This can be readily ascertained by looking across the surface 
of the fluid with the eyes on a level with the top of the 
cylinder. A convexity or concavity of the water side can 
be easily obviated. A convexity on the side which contains 
the blood should be avoided. When the cylinder is in posi- 
tion, the division containing the distilled water is over the 
colored glass. The reflector should be arranged to throw as 
much light as possible when the percentage of hemoglobin 
is high ; but when the hemoglobin is much diminished, less 
light will give more exact results. To perform the test one 
eye should be closed and the face shielded from direct light 
by holding a piece of paper between the face and the lamp. 
The instrument should be arranged so that the observer 
stands at the side of it and looks directly down into the 
fluid. This is done so that the images of both divisions of 
the cylinder are thrown upon the retina side by side, and 
not one above the other. This permits a more accurate 
comparison of colors to be made. By means of the adjust- 
ment screw move the colored glass from a point where the 
glass is paler than the diluted blood to a point where the 
color of the glass and of the blood match. Then read the 
percentage on the scale, and control the result by moving 
the colored glass from above the point where the colors 
match downward, to see if the same result is obtained ; pause 
a moment and repeat the test. More accurate results are 
obtained by resting the eye several times than by looking 
for a long time. 

In order to estimate the number of red corpuscles 
in a cubic millimeter of blood it is necessary to use a dilut- 
ing fluid. It is desirable that this fluid should be of such a 



334 PATHOLOGICAL TECHNIQUE. 

character that the corpuscles may not change their form or 
lose their color. Various fluids are used. Toison's fluid 
possesses the advantage of staining the white corpuscles. 
The formula of this fluid is as follows : 



Distilled water, 


160 


c.c. ; 


Neutral glycerin, 
Sodium sulphate, pur., 
Sodium chlorid, 


30 
8 

1 


it 

grams ; 
gram; 


Methyl-violet, 5 B, 


0.025 


a 



This fluid must be filtered each time before using. A drop 
of blood is required of sufficient size to more than fill the 
capillary tube of the " mixing pipette." If the drop is too 
small, it is difficult to prevent the entrance of air and coagu- 
lation of the blood in the tube in the interval of obtaining a 
second drop of blood. It is advisable, therefore, to perform 
this test before estimating the hemoglobin or making the 
cover-glass preparations. While filling the capillary tube of 
the pipette care must be exercised to keep the point of the 
pipette beneath the surface of the blood-drop to prevent the 
entrance of air. The blood is sucked up to the mark .5 or 
1., and then the tip of the tongue is pressed firmly over the 
hole in the mouth-piece. This prevents the blood-column 
from sinking or air from entering below while the tip of the 
pipette is being wiped and immersed in the diluting fluid. 
This part of the test requires the utmost precision and avoid- 
ance of delay. It is necessary, therefore, to keep the eyes 
constantly fixed on the capillary tube in order to note any 
variation in the blood-column. Rapidly wipe the tip of the 
pipette to remove the blood from the outside, and then im- 
merse the tip in the diluting fluid. Suck the fluid up to the 
mark 10 1, close the ends of the pipette with the thumb and 
middle finger, and shake the pipette for two minutes. If 
the ends of the pipette are not completely closed during this 
process, some of the fluid will escape. At the end of 
two minutes allow two drops to escape from the pipette 
before examination, because the fluid in the capillary tube is 
unmixed with blood. Then allow a drop to escape upon the 



HIS TOL O GICA L ME THODS. 



335 



central part of the counting slide. This drop should com- 
pletely fill the depression after the cover-glass has been 
applied. A little practice is necessary in order to estimate 
the size of the drop required. A moderately thick cover- 
glass should be slid over or carefully laid upon the square 
raised surface, and pressure applied to the edges until the 
Newton color-zone can be seen between the cover-glass and 
the square raised surface beneath. Never press on the 
center of the cover-glass. Allow the blood-corpuscles to 
settle a minute or two before counting. 

The corpuscles are estimated as follows : One side of a 
small square is -^ mm. long ; the enclosed square surface is 
4^-q mm. The distance between the cover-glass and the 



disc is .1 mm. which gives a cubic capacity of 40V0 c - mm - 
for each square. To estimate the number of corpuscles in 
I c.mm. of blood, multiply the number of corpuscles counted 
by 4000, and then by the number representing the amount 
of dilution, 100 or 200 as the case may be, and divide the 
result by the number of squares counted. 

Corp. X dilution X 4000 , 

+- - = corpuscles in 1 c.mm. 

Squares counted 

To avoid counting any of the corpuscles twice, always 
begin at the upper left-hand square of a quadrant and count 
four squares downward. Count all the corpuscles which 
touch the upper and left-hand lines of a square, together 
with the corpuscles in the square. Never count the cor- 
puscles touching the right-hand or lower double lines of a 
quadrant. In order to make an accurate count it is neces- 
sary to count at least 1200 red corpuscles. 

If air-bubbles are present when the cover-glass is applied, 
it is necessary to clean the slide and use a fresh drop of the 
diluted blood. Before beginning the count examine the 
various quadrants with a low-power objective, to see if the 
corpuscles are evenly distributed. If they are not, it will be 
because the blood is not thoroughly mixed, and the slide 
should be washed and the pipette well shaken. Before ex- 
amining a second drop of the diluted blood shake the 



336 PATHOLOGICAL TECHNIQUE. 

pipette for two minutes as before. The results of three 
drops should be averaged. 

There is a special pipette for counting the white corpuscles, 
graduated so as to give a dilution of i to 10 or I to 20. 
The white corpuscles are estimated in the same way as the 
red corpuscles, except that the dilution 10 or 20 is sub- 
stituted for 100 or 200. This necessitates a fresh drop of 
blood. For a diluting fluid for counting the white corpuscles 
a J or J per cent, solution of acetic acid may be used. This 
solution destroys the red corpuscles. A little gentian-violet 
solution may be added to the acetic acid if it is desired to 
stain the white corpuscles. 

It is possible to estimate both the white and red corpuscles 
in the same drop of blood quite accurately. In order to do 
this it is necessary to calculate the number of squares which 
would be contained in the entire ruled surface outside of the 
portion which is divided into quadrants. This may be done 
by means of a micrometer eye-piece and a movable stage. 
The number has been found to be about 2000, although 
there may be some slight variation in each slide. This enables 
one to count 50 white corpuscles or more in each drop by 
counting all the corpuscles within the lines. For calculating 
the number of corpuscles one would divide by the estimated 
number of squares counted, just as in determining the red 
corpuscles. The average of three drops gives quite accurate 
results and saves much time and trouble. 

Cover-glass Preparations. — The blood must be spread 
extremely and uniformly thin. If this is done, the blood 
dries very quickly, and the red blood-corpuscles retain their 
shape and are not crowded together and lying over one an- 
other. To obtain such a result it is essential that the cover- 
glasses should be absolutely clean ; that there should be no 
delay in bringing the cover-glass which has the drop of blood 
on its surface in contact with a second cover-glass ; and that 
the drop of blood should be quite small. The following 
method gives the best results : The procedure is rendered 
much easier if some one is present to assist. This person 
places a finger beneath the lobe of the ear in order to raise 



HISTOLOGICAL METHODS. 



337 



it slightly without pressing upon it, and with a clean com- 
press wipes away the blood as fast as it flows with a quick 
motion of the hand. This is done to prevent coagulation, 
which occurs very quickly, and prevents the drop of blood 
from spreading between the cover-glasses. It takes a little 
time for the blood to spread, the cover-glasses to be sepa- 
rated and laid down, and fresh ones picked up ; and if, during 




FIG. 102. — Forms of forceps for holding cover-glasses. 

this time, some one wipes away the blood as fast as it flows, 
much better preparations are obtained. If, in spite of this, 
as often happens, the blood coagulates about the opening, 
one end of the compress can be slightly moistened with 
water and passed over the opening and the surface dried 
quickly. The blood then flows freely again. A drop of 
blood a little larger than a pin-head is sufficient. Grasp the 
edge of the cover-glass with a pair of spring forceps, pick up 
a second cover-glass with a pair of plain forceps. Both 
pairs of forceps must be especially prepared by having the 
inner surfaces of the points ground smooth. The cover-glass 
in the spring forceps is held horizontally just below the ear, 
and the other cover-glass, held with the other forceps, is 
touched lightly on the blood and immediately dropped on 
the first one. If the cover-glasses are dry and clean and the 

22 



33§ PATHOLOGICAL TECHNIQUE. 

blood has not begun to coagulate, it spreads at once in a 
thin film between the glasses. The glasses are then drawn 
apart with a rapid sliding motion by means of the forceps, 
waved in the air a few seconds, and laid down with the blood- 
surface uppermost. The layer of blood cannot be too thin, 
but it can easily be too thick. The cover-glasses should 
never be pressed together to make the blood spread. Con- 
siderable practice is required before one becomes proficient. 
The specimens may be fixed by heat or by a mixture of al- 
cohol and ether, equal parts. The best method is to put the 
cover-glasses for twelve hours in a thermostat at a tempera- 
ture between no° and 120 C. (Ehrlich's method). This is 
objectionable on account of the time and apparatus required. 
A practical modification of this method is to heat the cover- 
glasses on a brass plate for an hour at a point on the plate 
where water boils. The plate should be about -§- of an inch 
thick and from 15 to 18 inches long. It should be heated 
from one end to a constant temperature. Test the degree of 
heat with drops of water and select a part where the water 
boils. At a point nearer the flame it will be found that the 
water sputters and rolls about, indicating too high a temper- 
ature. After putting the cover-glasses, with the blood-side 
uppermost, upon the selected point, it is necessary to test the 
degree of heat from time to time, and perhaps to shift the 
cover-glasses. 

A shorter and easier method, not so satisfactory, is to fix 
the specimens by immersing them for from thirty minutes to 
an hour in a mixture of absolute alcohol and ether, equal 
parts. This gives good results, as a rule. 

The Elements of the Blood. — Red corpuscles, white 
corpuscles, and hematoblasts. The red blood-corpuscles (ery- 
throcytes) are biconcave discs. The diameter of a red blood- 
corpuscle in human blood is the same for male and female, and 
averages 7.8/*. The red corpuscles have a pale-yellow color 
with a faint tinge of green ; they are homogeneous, highly 
refractive, and have no nuclei (normally). Outside the cir- 
culating blood the corpuscles rapidly undergo alterations in 
their shape and size. These changes may be prevented or 



HISTOLOGICAL METHODS. 339 

hindered, for purposes of study, by appropriate 'methods of 
fixation and preservation. The average number of red cor- 
puscles in 1 cubic millimeter of human adult blood is from 
four million to five million. Under abnormal conditions the 
red corpuscles vary in size, shape, and number, and a small 
proportion of them may have nuclei. 

1. Variations in the shape (poikilocytosis) are of frequent 
occurrence. Some of the corpuscles may be pear-shaped or 
bottle-shaped ; others may be shaped like saddle-bags or 
have projections. Variations in the size of the erythrocytes 
are also common. They all retain the central depression, 
notwithstanding the variations in shape and size. 

2. Abnormally large erythrocytes, varying from 10 to 14/i 
in diameter and without nuclei, are called megalocytes. Very 
small erythrocytes, varying from 2 to 5// in diameter, are 
called microcytes. The microcytes contain hemoglobin, but 
do not have the central depression. 

3. Nucleated red corpuscles (erythroblasts) occur in two 
forms, the so-called normoblasts and the megaloblasts or 
gigantoblasts. A normoblast is the same size as a normal 
corpuscle, but contains a single relatively large nucleus. 
The nucleus is commonly situated in the centre of the cor- 
puscle, but it may lie in the periphery, and takes a more 
intense stain than the nucleus of any other corpuscle. 
Mitosis is observed frequently. Free nuclei are found 
often. A megalo- or gigantoblast is from three to five 
times as large as a normal red corpuscle, and contains a 
relatively large round nucleus in the center. The intensity 
with which this nucleus stains is midway between that 
of the normoblast nucleus and the nuclei of the white cor- 
puscles. 

4. The so-called anemic degeneration of the red corpuscles 
is less commonly met with than the preceding changes. 
When cover-glass-preparations are stained with eosin-hema- 
toxylin or eosin-methylene-blue, the red corpuscles, instead 
•of staining a bright eosin-red, take a muddy-looking, darker 

stain. This appearance is assumed to be due to degenera- 
tive changes in the stroma of the corpuscles, which cause 



340 PATHOLOGICAL TECHNIQUE. 

the hemoglobin to become stained to some extent by the 
nuclear stain in addition to the eosin. 

The white corpuscles (leucocytes) differ in size, in the size 
and shape of their nuclei, and in the granules which are con- 
tained in the protoplasm. They have been classified in vari- 
ous ways, depending upon their supposed origin and upon 
the granules which they contain. 

Ehrlich differentiates five different kinds of granules found 
in the human blood : the a or eosinophilic granules ; the ft 
or amphophilic ; the o and y or basophilic granules ; and the 
£ or neutrophilic granules. 

The a or eosinophilic granules are coarse, round or oval, 
highly refractive granules which have an affinity for the acid 
aniline stains, especially eosin. 

The ft or amphophilic granules have an affinity for both 
acid and basic stains. They occur very rarely in human 
blood, but are common in the blood. of certain animals. 

The d and y granules are finer and less refractive granules 
which have an affinity for basic stains. The y granules are 
nearly as large as the eosinophilic granules, but are not so 
refractive. The 3 granules are much finer and not very re- 
fractive, and are very numerous in the cells in which they 
occur. 

The e or neutrophilic granules are much smaller, more 
numerous, and less refractive than the eosinophilic granules, 
and have an affinity for neutral stains. They occur only in 
human blood. 

Morphologically, there are five varieties of white cor- 
puscles. They are — the small mononuclear cell or lympho- 
cyte ; the large mononuclear cell ; the transitional large 
mononuclear cell ; the neutrophile ; and the eosinophile. 
The small mononuclear cell or lymphocyte is slightly larger 
than a red corpuscle, and has a single round nucleus sur- 
rounded by a narrow strip of protoplasm which contains no 
granules. The nucleus stains more intensely than the nuclei 
of the other white corpuscles. 

The large mononuclear cell is much larger than the 
lymphocyte, and contains a large, oval or round nucleus 



HISTOLOGICAL METHODS. 34 1 

surrounded by a wide zone of protoplasm. The nucleus 
takes a fainter stain than that of the lymphocyte. 

The transitional large mononuclear cell differs from the 
large mononuclear only in having a saddle-bag-shaped 
nucleus. Variations in size are frequently observed in the 
small mononuclear as well as in the large mononuclear cells, 
so that under some circumstances it is difficult to distinguish 
to which type of cell a given cell belongs. 

The neutrophile or polymorpho-nuclear leucocyte is about 
three times as large as a red corpuscle. This cell is the so- 
called polynuclear leucocyte found in pus. The nucleus, as 
the name implies, is more or less subdivided, and often re- 
sembles various letters, as S, Z, V, M, etc. The nucleus is 
surrounded by a relatively large amount of protoplasm 
which is more or less completely filled with fine neutrophilic 
granules. 

The normal eosinophile resembles the neutrophile in size 
and in the character of its nucleus. It differs from the 
neutrophile, at least chemically, by containing the eosinophilic 
a granules. 

The large mononuclear, transitional, and neutrophilic cells 
are regarded as the same cell in different stages of develop- 
ment. The younger form is the large mononuclear, and 
the oldest is the neutrophile. During the process of " ripen- 
ing," as it is called, the fine e granules are formed in the pro- 
toplasm, and the nucleus becomes more or less subdivided. 

The so-called mastzellen — that is, cells which contain baso- 
philic granules — were supposed by Ehrlich to originate from 
fixed connective-tissue corpuscles and from the spleen, and 
not to be present normally in the blood. Later investiga- 
tions show that an occasional viastzelle may be found in 
normal blood. 

Markzellen, or myelocytes, is the name applied to large 
mononuclear cells containing neutrophilic, and sometimes 
eosinophilic, granules. These cells are present in the 
medullary cavity of the long bones, but are never found in 
the blood normally. 

Hematoblasts {blut-plattche?i) are small round or oval discs 



342 PATHOLOGICAL TECHNIQUE. 

from 1.5 to 3.5// in diameter. They do not contain hemo- 
globin and have no central depression. They are so rapidly 
disintegrated on exposure to the air that it is necessary to 
use special precautions in order to preserve them. The best 
way to study them is to put a drop of some preserving fluid 
on the skin from which the blood is to be obtained, and then 
puncture the skin through the fluid. A 1 per cent, aqueous 
solution of osmic acid can be used, or, if it is desired to 
stain them, 1 part of methyl-violet in 5000 parts salt solution 
may be used. 

Methods of Staining.— Of the many staining fluids 
which have been employed to differentiate the white cor- 
puscles, it is necessary to mention only those which are com- 
monly used and which have been found to answer all pur- 
poses. 

Ehrlich's triple stain possesses the advantage of staining 
both the eosinophilic and neutrophilic granules in addition to 
the nuclei. The formula is as follows : 



Orange G, 
Distilled water, 


135 gms.: 
100 " 


Acid fuchsin, 
Distilled water, 
Absolute alcohol, 


65 " 
100 " 
100 " 


Methyl green, 
Distilled water, 


125 " 

100 " 


Absolute alcohol, 
Glycerin, 


100 " 
100 " 



The various ingredients are prepared separately as indi- 
cated by the dotted lines, and are afterward mixed gradually. 
The mixture must stand for several weeks before using. It 
is advisable to withdraw by means of a pipette some of the 
staining fluid from the middle portion without disturbing the 
bottom. 

The cover-glass preparations should be stained from six to 



HISTOLOGICAL METHODS: 343 

eight minutes, washed, thoroughly with water, dried, and 
mounted in Canada balsam. The neutrophilic granules are 
stained violet ; the eosinophilic, a bright red ; the nuclei of 
the neutrophilic and the eosinophilic cells are a greenish- 
blue ; the nuclei of the lymphocytes, a deep blue ; the nu- 
clei of the large mononuclear cells, a pale blue ; the red cor- 
puscles, copper color : and the nuclei of the red corpuscles, 
if any be present, a more intense blue than the nuclei of the 
lymphocytes. For some unexplained reason this stain is 
not always uniform in its action. 

It is sometimes difficult to distinguish a nucleated red cor- 
puscle from a lymphocyte. It is well to remember, there- 
fore, that the nuclei of red corpuscles stain more intensely 
than other nuclei, and have very sharply defined outlines, 
and by careful focussing it is seen that the surrounding 
stroma is stained the same color as the other red corpuscles. 

Ehrlich's Hematoxylin-eosin Stain. — 

Distilled water, 

Alcohol, 

Glycerin, da. 100 grams ; 

Hematoxylin, 4-5 " 

Acetic acid, 20 " 

Alum in excess. 
The mixture remains from four to six weeks in the sun, 
and then about I per cent, of eosin is added. Stain for from 
twelve to twenty-four hours in a covered glass dish in the 
sun. Wash thoroughly in water, dry, and mount in Canada 
balsam. 

The red corpuscles are stained red, with at times a tinge 
of orange ; the nuclei of the red corpuscles, a deep black ; 
the protoplasm of the leucocytes, a light lilac ; the nuclei, a 
dark lilac ; the eosinophilic granules, a bright red ; the nu- 
clei of the lymphocytes, black, with not quite so deep a tinge 
as the nuclei of the red corpuscles. The protoplasm scarcely 
stains. 

Eosin and Methylene-blue Stains. — Separate stain. The 
eosin solution, a \ per cent, alcoholic solution, is heated and 



344 PATHOLOGICAL TECHNIQUE. 

the cover-glasses are stained in it from two to three minutes, 
and are then stained in a saturated aqueous solution of 
methylene-blue for from two to three minutes ; thoroughly 
washed, dried, and mounted in Canada balsam. 

The red corpuscles are stained eosin red ; the nuclei of the 
red corpuscles, a deep-blue ; the nuclei of the leucocytes 
are stained a light blue ; the eosinophilic granules, a bright 
red. 

Chenzinsky-Plein Solution. — Saturated aqueous solution 
of methylene-blue, 40 c.c. ; \ per cent, (in 70 per cent, alco- 
hol) eosin solution, 20 c.c. ; distilled water, 40 c.c. 

The best results are obtained by staining the specimens for 
twenty-four hours. A fairly good stain may be obtained by 
heating the solution fifteen minutes. The red corpuscles are 
stained eosin red ; the eosinophilic granules, a bright red ; and 
the nuclei, blue. 

The basic granules may be stained by a concentrated so- 
lution of methylene-blue. The specimens should remain in 
the solution from five to ten minutes. 



METHODS OF FIXING AND EXAMINING SPECIAL OR= 
GANS AND TISSUES. 

Tissues which are to be hardened should be obtained as 
fresh as possible. For this reason autopsies rarely furnish 
such perfect material as is obtainable from experimental le- 
sions in animals or from surgical operations. Still, most of 
the pathological material comes from autopsies, and it is en- 
couraging to know that very good work can often be done 
with tissues not fixed until twenty-four hours or even more 
after death. The most valuable autopsies are those which 
are freshest, and in which but one etiological factor has been 
concerned, so that the relation between the cause and the le- 
sion produced is uncomplicated and can be readily grasped 
and understood. 

The choice of the proper fixing reagent varies with the 
tissue, the lesion, and the use to which the material is to be 



HISTOLOGICAL METHODS. 345 

put. For simple diagnosis alcohol is usually sufficient. For 
special investigations other fixatives may be required. In 
general it may be said that alcohol is best suited for bacteria 
.and for many micro-chemical color reactions ; Zenker's or 
Orth's fluids for red blood-globules, nuclear figures, and pro- 
toplasm ; formaldehyde for the central nervous system. 
More attention will be paid to this point in the consideration 
of the separate organs and tissues. 

It is important that pieces of tissue for histological study 
should be placed in the proper fixative as soon after the re- 
moval of the organs from the body as possible, so that the 
surface will not dry or the blood and other fluids escape from 
the vessels. Do not wash off the surface with water. The 
tissues should almost invariably be cut into thin slices, not 
over J to I cm. thick. For the finer fixatives 2 mm. should 
not be exceeded. 

Frozen sections of fresh tissues will often show whether 
the material is worth saving, and suggest what fixatives had 
best be used — such as Flemming's solution, for instance, if 
fat is present. 

Acute Inflammatory Exudations; Granulation- 
tissue. — The elements in acute inflammatory exudations 
which require preservation are polynuclear leucocytes, 
serum, fibrin, and red blood-globules. The best general 
fixative for them all is Zenker's fluid. It not only pre- 
serves perfectly the characteristic nuclei of the leucocytes, 
but also the protoplasm which stands out sharply in con- 
trast-staining with eosin. The albumin of the serum is 
coagulated into a finely granular material. The fibrin and red 
blood-globules stain brilliantly with eosin. Alcohol is gen- 
erally preferred for the fixation of any organisms associated 
with the exudation, but after fixation in Zenker's fluid they 
can be perfectly stained with Unna's alkaline methylene-blue 
solution. Occasionally other fixatives, such as Flemming's 
or Pianese's, will be found useful, especially for the study of 
any attendant degenerations. 

Zenker's fluid will also be found invaluable for fixing 
granulation-tissue where a similar exudation is generally 



346 PATHOLOGICAL TECHNIQUE. 

combined with new-formed blood-vessels and connective 
tissue. 

For the study of the plasma-cells which early make their 
appearance in granulation-tissue hardening in alcohol is gen- 
erally advisable, although Zenker's fluid is often to be pre- 
ferred, and for eosinophiles is indispensable. 

I/tmg. — In the preservation of the lungs it is important 
to save portions that have not been squeezed, so that the 
relations of the exudations may not have been changed or 
the alveoli compressed. Thin slices are usually preferable 
to cubical pieces, and should be cut with a very sharp knife, 
so as not to compress the tissue, and dropped immediately 
into the fixing fluid, before the contents of the bronchi and 
of small cavities have had time to run out. An emphysem- 
atous lung is so delicate that it is usually better to inject a 
whole lung through the bronchi with the fixing fluid or to 
snip out small pieces with scissors. Zenker's fluid and 
alcohol are the most useful fixatives. 

Spleen. — The spleen-pulp may be examined by means 
of dried cover-slip preparations in the same way as described 
for the blood. Material can be obtained immediately after 
death by means of a long trocar thrust into the spleen. 
Teased preparations can be examined in salt solution. The 
spleen-tissue is well preserved in Zenker's fluid if cut into 
thin pieces not over \ cm. thick. Paraffin sections are to be 
preferred when convenient, so that the thinnest possible sec- 
tions may be obtained. 

Bone-marrow may be examined in the same way as 
spleen-plup in cover-slip preparations, or small bits may be 
hardened in Zenker's fluid or some other fixative for study 
by means of sections. 

Kidney. — The choice of fixing reagents varies largely 
with the lesions present. Zenker's fluid is advisable for 
general histological purposes, for blood, and for hemo- 
globin ; alcohol for bacteria, amyloid, hemosiderin ; Flem- 
ming's for fat; boiling water for albuminous exudations. 
The pieces of tissue preserved should include both cortex 
and pyramids. 



HISTOLOGICAL METHODS. 347 

In cases, of chronic nephritis the capsule should not 
be peeled from those parts kept for microscopical pur- 
poses. 

Paraffin imbedding is generally to be preferred for the 
kidney, especially when lesions of the glomeruli are present. 

For the simple demonstration of fat, teased preparations 
or frozen sections of fresh material can be mounted in water 
and treated with acetic acid. 

Gastro-intestinal Tract.— Portions of the stomach or 
intestine should be hardened as soon after death as possible 
for satisfactory study, because the gastro-intestinal tract so 
rapidly undergoes post-mortem changes. It has been recom- 
mended in appropriate cases, where an autopsy is allowable, 
to inject the stomach with the desired fixing solution by 
means of a rubber tube as soon after death as is permissible. 
Under no circumstances should the surface of the intestine 
or stomach be washed with water. Use either normal salt 
solution or some of the fixing solution. It is important to 
keep the tissue flat while hardening. This can usually be 
done by laying it with the peritoneal surface down on thick 
filter-paper, to which it readily sticks. Sometimes it is 
necessary to pin the specimens down at the edges on flat 
pieces of cork. Do not let the surface dry before the speci- 
men is placed in the fixing solution. Zenker's fluid can be 
highly recommended as a fixative, but alcohol is sometimes 
to be preferred. 

I/iver. — For fat the liver is examined fresh in teased prep- 
arations or frozen sections, or after hardening in Flemming's 
or Marchi's solution, by means of celloidin or paraffin sec- 
tions. 

For obtaining the iron reaction with hemosiderin in cases 
of pernicious anemia, and for the reactions of amyloid, harden 
in alcohol. 

For general histological study Zenker's fluid will be found 
exceedingly useful. 

The bile-capillaries may be demonstrated by means of 
Golgi's silver method. 

Boehm's directions for it are as follows : 



348 PATHOLOGICAL TECHNIQUE. 

1. Harden pieces of liver I cm. in diameter for seventy 
hours or more in 

3 per cent, solution of bichromate of potassium, 4 parts ; 
1 per cent, solution of osmic acid, 1 part. 

2. Transfer for twenty-four to forty-eight hours to a f per 
cent, solution of nitrate of silver. 

3. Wash in water. 

4. Harden and cut. 

The bile-capillaries appear dark brown on a yellow ground. 

Bone and Cartilage. — Excellent work can be done after 
hardening in alcohol, and fixation in it is generally recom- 
mended for all infectious processes in bone. The histological 
structure is, however, better preserved in Zenker's or Orth's 
fluid. In decalcifying bone, after proper fixation, thin pieces 
should be taken, not more than 2 to 4 mm. thick, so that the 
process may be finished as quickly as possible. While tu- 
bercle bacilli will stain readily after being twenty-four or even 
forty-eight hours in 5 per cent, nitric acid, it is impossible 
to stain them after they have been subjected to the same 
strength of nitric acid for four days. (For details in regard 
to decalcification see page 228.) 

Celloidin is preferable to paraffin for imbedding. Besides 
a simple stain with alum-hematoxylin, double stains of the 
latter with neutral carmine or eosin are sometimes advanta- 
geous. The best pictures with carmine as the contrast-stain 
are obtained by staining first in alum-hematoxylin, washing 
twelve to twenty-four hours, and then staining in the neutral 
carmine. The carmine stains decalcified bone and osteoid 
tissue red. Phosphotungstic-acid hematoxylin will some- 
times be found useful, especially when cartilage is present, 
because it stains the intercellular substance both of bone and 
of cartilage pink, while the nuclei are stained blue. The 
ground substance of cartilage, especially in new-growths, 
often stains so intensely with alum-hematoxylin that the 
nuclei are quite obscured. 

The following method is recommended for differentiating 
cartilage from bone : 



HISTOLOGICAL METHODS. 



349 



Schaffer's Safranin Method. — Decalcify with nitric acid. 

1. Stain sections a half to one hour in an aqueous solution 
of safranin, i : 2000. 

2. Wash in water. 

3. Place for two to three hours in a ^ per cent, solution 
of corrosive sublimate. 

4. Examine in glycerin, or, if permanent specimens are 
desired, pass very quickly through alcohol, blot with filter- 
paper, further dehydrate, and clear for a long time in berga- 
mot or clove oil, and mount in xylol balsam. This is a 
double stain : cartilage, orange ; bone, uncolored ; connective 
tissue and marrow, red. 

None of the methods above given have proved reliable in 
the study of rickets and of osteomalacia for differentiating os- 
teoid from true bone-tissue. In important cases, therefore, it 
is advisable to use an old knife, and to cut sections of the 
undecalcified tissue after imbedding thoroughly in celloidin. 

Skin. — Much of the material for the study of lesions of 
the skin is obtained during life by means of a Mixter punch 
or with the knife or scissors. Fixation in absolute alcohol is 
often advisable, especially when it is desired to stain bacteria, 
mastzellen, plasma-cells, and elastic fibers. The staining 
methods for these tissue-elements will be found on pages 
300, 302. For Unna's innumerable stains for degenerated 
connective-tissue fibers, elastic fibers, etc. the reader is re- 
ferred to his numerous articles on technique in the Monat- 
sheft. f. prakt. Dermatologie during the last half-dozen years. 

For many skin-lesions, especially those in which blood- 
vessels play a more or less prominent part, Zenker's fluid is 
advisable. For finer histological work Pianese's fixatives and 
special stains are recommended. 

In the examination of hairs or scales of epidermis for 
bacteria and fungi it is important first to remove the fat from 
them by means of equal parts of alcohol and ether. They 
are then examined in 40 per cent, caustic potash, which, by 
clearing up the cells, brings out the organisms and spores 
quite distinctly. Heating the potash over a small flame 
hastens the process, but is a somewhat risky proceeding; 



350 PATHOLOGICAL TECHNIQUE. 

soaking in the solution over night is better. Examine the 
preparation with most of the light excluded. 

Preparations may be made in certain cases by touching the 
cover-slip to the surface of the lesion, drying, and passing 
through the flame. After removing the fat by means of al- 
cohol and ether, stain as with ordinary cover-slip preparations. 

Unna's method is to rub up the scales of epidermis in a 
little glacial acetic acid between two slides, which are then 
drawn apart and quickly dried over the flame. After re- 
moving the fat by means of alcohol and ether the slide 
preparations are stained in borax-methylene-blue. 

For staining the various vegetable parasites of the skin 
Malcolm Morris recommends the following method, which 
he claims is the best one yet devised, as it avoids the use of 
the hydrate of potash : 

1. Ether, or alcohol and ether equal parts. 

2. Stain in a solution of 5 per cent, gentian-violet in 70 
per cent, alcohol, five to thirty minutes. 

3. Iodin solution, one minute. 

4. Aniline, or aniline plus 2 to 4 drops of nitric acid. 

5. Aniline. 

6. Xylol. 

7. Xylol balsam. 

The most suitable medium for the growth of the various 
ringworms is the following, due to Sabourand : 

Agar-agar, 1.30; 

Peptones, .50; 

Maltose, ' 3.80; 

Water, 1 00. 

Instead of test-tubes, Ellenmeyer flasks are used, so as 
to get a large flat surface for the growth to spread over from 
the point of inoculation in the center. The most favorable 
temperature for growth is 30 C. 

Museum Preparations. — Specimens .intended to be 
preserved for the museum should generally be gotten into 
pretty good shape by trimming and dissecting before they 
are placed in the hardening reagent. Of the liver or other 



HISTOLOGICAL METHODS. 35 I 

large organs and tumors sections several cm. thick are gen- 
erally preferable to the whole specimen. The usual custom 
in the past has been to wash the specimen for a number of 
hours or over night in running water, to get rid of the blood, 
and then to preserve in 80 per cent, alcohol. This method 
preserves form and relations well, but is nearly valueless for 
preserving colors. 

Since the introduction of formaldehyde, from which at 
first much was expected in the way of faithful fixation of 
the normal colors of gross preparations, numerous attempts 
have been made to improve on the results obtainable with 
formaldehyde alone. Of the methods advocated, the follow- 
ing from Virchow's laboratory seems the most promising, 
and can be highly recommended : 

Kaiserling's Method of Preserving the Natural Colors 
in Museum Preparations. — 1. Fixation for one to five days 
in — 

Formaldehyde, 200 c. c. ; 

Water, 1000 " 

Nitrate of potassium, 1 5 grams ; 

Acetate of potassium, 30 " 

Change the position of the specimen frequently, using rubber 
gloves to protect the hands from the injurious effect of the 
formaldehyde. The time of fixation varies with the tissue 
or organ and size of the specimen. 

2. Drain and place in 80 per cent, alcohol one to six hours, 
and then in 95 per cent, alcohol for one to two hours, to re- 
store the color, which is somewhat affected in the fixing 
solution. 

3. Preserve in — 

Acetate of potassium, 200 grams ; 

Glycerin, 400 c.c. 

Water, 2000 " 

Exposure to light gradually affects the colors. The process 
of fixation should be performed in the dark, and the speci- 
mens when preserved should be kept in the dark except 
when on exhibition. 



352 PATHOLOGICAL TECHNIQUE. 

If it seem desirable to cut a thin slice from the face of a 
specimen, this should not be done until the preparation has 
been in the preservative fluid two weeks. The specimen 
may then be placed in alcohol for one to two hours to 
brighten up the colors. 



PATHOLOGICAL PRODUCTS. 

Cloudy Swelling; Albuminous Degeneration. — 

The increase in the relative number of the albuminous 
granules of the protoplasm of the various tissue-cells in 
pathological processes is usually determined by examination 
of the fresh material, either macroscopically from the appear- 
ances on section, or microscopically from teased preparations 
or frozen sections mounted in salt solution. The organ as a 
whole (and therefore the individual cells) usually shows 
some increase in size. The nucleus is generally more or 
less obscured if the process is at all marked. According to 
Israel, the cloudiness must be recognizable with low powers 
and in places where the cells are massed together. The 
diagnosis should not be based on the appearances of single 
cells. 

The chemical properties of the albuminous granules are 
the following : they disappear on treatment with dilute acetic 
acid (1-2 per cent, solution usually); they are not dissolved 
by chemical substances which dissolve fat (absolute alcohol, 
ether, chloroform, etc.) ; and they do not stain with osmic 
acid. The acetic-acid test is the one usually employed. 

Albuminous degeneration can also be studied in sections 
of tissues hardened in certain of the fixatives and stained with 
diffuse colors. For this purpose hardening in Zenker's fluid 
and staining in alum-hematoxylin and eosin can be highly 
recommended. 

Fatty Degeneration. — Fatty degeneration can be 
studied both in fresh and in properly hardened tissues. The 
recognition of fat in fresh specimens depends, aside from its 
physical peculiarities, on the following chemical properties : 

I. It does not disappear on the addition of acetic acid. 



HISTOLOGICAL METHODS. 353 

2. It resists the action of dilute caustic potash or soda. 

3. It is blackened by osmic acid. 

4. It is dissolved (after dehydration in alcohol) by chloro- 
form, ether, etc. 

The tests usually employed with teased preparations or 
frozen sections of fresh tissues are the reactions with acetic 
and osmic acids. The acetic acid is usually employed in a 
1 or 2 per cent, solution, of which a few drops are placed at 
the edge of the cover-slip and drawn under by means of a 
bit of filter-paper placed at the opposite edge. The osmic 
acid in a 1 per cent, solution may be used in the same manner 
for teased preparations, or the tissue may be teased apart in 
a small quantity of the fluid. Frozen sections can be placed 
directly in it. 

Fat is unaffected by formaldehyde or by solutions of the 
chrome salts, so that tissues preserved in them may be ex- 
amined like fresh tissues in teased preparations or frozen sec- 
tions mounted in water, so long as they remain in those 
fluids. This no longer holds true, however, after the tissues 
have once been transferred to alcohol. 

The examination of fat in hardened tissues depends on its 
property of reducing osmium and thereby being stained 
black. Although osmic acid may be used alone for harden- 
ing tissues and staining fat, it is generally employed in com- 
bination with certain other fixatives. The two solutions 
generally selected are Flemming's and Marchi's. 

Flemming's solution should be allowed to act from two to 
four days if the tissue is from 2-3 mm. thick, and then the 
pieces of tissue should be thoroughly washed in running 
water for twenty-four hours before being placed in alcohol. 

Marchi's method was intended for differentiating fat from 
myelin (see page 228), but the solution employed by him 
may be used for staining fat in ordinary tissues. Place small 
pieces of tissue in it for five to eight days, wash thoroughly 
in running water, and harden in alcohol. 

Marchi's method, carried through in the manner just de- 
scribed, succeeds perfectly with tissues hardened in formal- 
dehyde. 



354 PATHOLOGICAL TECHNIQUE. 

Fat stained with osmium is soluble in ether, turpentine, 
xylol, toluol, and very slowly in chloroform, but is not dis- 
solved by alcohol or oil of cloves. Imbedding in celloidin 
is not contraindicated, as the alcohol probably protects the 
fat from the injurious action of the ether. For the paraffin 
method, chloroform or a mixture of oil of cloves and xylol 
equal parts will give good results if it is not allowed to act 
too long. Mount in thick xylol or chloroform balsam. 

Cholesterin crystals are recognized by their shape. On the 
addition of concentrated sulphuric acid the crystals turn 
yellow, and then rose-color. Treated with a little iodin, fol- 
lowed by concentrated sulphuric acid, they become colored 
violet, changing gradually to blue, green, and red. 

Necrosis. — Necrosis in tissues is generally recognized by 
two features : either by the disappearance of the nuclei, al- 
though the cell-outlines may be visible, so that the nuclear 
stain is no longer possible, or by the presence of irregular, 
larger or smaller masses, generally supposed to be due to a 
fragmentation or breaking up of the chromatin, which stain 
intensely with nuclear stains. The disappearance of the nu- 
cleus is not synchronous with the death of the cell, but be- 
gins some twenty-four hours later, so that it is really evidence 
of changes following necrosis. It follows from the above 
that the microscopic evidence of necrosis is best studied in 
sections of tissues hardened in fixatives which favor nuclear 
staining, such as alcohol, Zenker's fluid, etc. Teased prep- 
arations and frozen sections of fresh tissue are much less 
useful. 

For the study of sections from hardened material double 
stains with alum-hematoxylin and eosin, or with eosin fol- 
lowed by Unna's alkaline methylene-blue solution, are very 
useful, for the reason that the necrotic areas usually stain 
rather deeply with the diffuse stain, and are thereby brought 
out sharply. 

For rendering the fragmented nuclei prominent the same 
methods may be followed as for mitosis. A fuchsin stain 
washed out by picric acid in the alcohol will often give ex- 
cellent results. 



HISTOLOGICAL METHODS. 355 

Caseation is probably a tissue-change following local 
necrosis. Macroscopically and microscopically it resembles 
harder or softer cheese. Under the microscope it appears 
as coarsely or finely granular masses which have more or 
less completely lost the original tissue-structure. The chem- 
ical changes which have taken place have not been studied. 
Fibrin is rarely present. Caseous tissue possesses no peculiar 
staining reactions. Fragmented nuclei are frequently pres- 
ent in it, especially in the peripheries of the areas. 

Demonstration of Fibrin.— Fibrin usually appears as 
delicate, transparent, slightly refractive threads which are 
often closely matted together so as to form large masses. 
More rarely it appears as coherent masses of the finest gran- 
ules, as homogeneous glassy lumps, or as thin sheets. The 
characteristic reaction for fresh fibrin is that it quickly swells 
up and optically dissolves in very dilute acetic acid. 

Fibrin is well brought out in sections of hardened tissues 
by a double stain of alum-hematoxylin and eosin, or of 
eosin followed by Unna's alkaline methylene-blue solution, 
especially if the specimens have been fixed in Zenker's fluid. 
Phosphotungstic-acid hematoxylin is often useful for staining 
fibrin after any of the hardening reagents. 

Of the differential stains for fibrin, the most important and 
useful is Weigert's : 

1. Harden in alcohol. 

2. Stain celloidin sections in lithium carmine. 

3. Fasten sections to slide with ether-vapor (see page 234). 

4. Stain in aniline-gentian-violet five to twenty minutes. 

5. Wash off with normal salt solution. 

6. Iodin solution 1:2: 100 one minute. 

7. Wash off with water. 

8. Decolorize in — 

Aniline, 2 parts ; 

Xylol, 1 part. 

9. Wash off with three changes of xylol. 

10. Canada balsam. 

The fibrin and those bacteria which are stained by Gram 



356 PATHOLOGICAL TECHNIQUE. 

are stained blue. The nuclei are red if the decolorization is 
carried far enough. It can easily be watched under the low 
power of the microscope. The method is not always suc- 
cessful, especially with tissues which are old. It is some- 
times advisable to increase the proportion of xylol in the 
decolorizing solution, so that the extraction of the color 
may not be so rapid. With paraffin sections fastened to the 
slide with egg-albumin use alum carmine as the contrast- 
stain, because the acid used with the lithium-carmine method 
will dissolve the albumin and loosen the sections. Besides 
the fibrin, certain forms of hyaline are often stained by this 
method. Fibrin can be stained by the above procedure in 
sections of tissues hardened in M tiller's fluid if the speci- 
mens are first placed for several hours in a 5 per cent, aque- 
ous solution of oxalic acid to reduce the bichromate of 
potassium. 

Mucin. — The term " mucin " is applied to a proteid sub- 
stance having certain chemical reactions, and also to certain 
other substances which give the same reactions, but do not 
belong to the proteids. These various substances of secre- 
tory and degenerative origin cannot be distinguished micro- 
scopically, and have been investigated but little chemically. 
The reactions in common are the following: they dissolve 
in water to form a slimy fluid ; they are precipitated from 
slightly alkaline solutions by acetic acid ; the fresh precipi- 
tate dissolves in alkalies and in neutral salt solutions. Acetic 
acid, usually employed for this purpose in a 1 or 2 per cent, 
solution, precipitates mucin in the form of threads or 
granules. This reaction with fresh tissues Has long been 
the main test for mucin. The acetic acid is drawn under 
the cover-slip by means of filter-paper placed at the opposite 
edge. The preparation should be mounted in water, not in 
salt solution, which may hinder or entirely prevent the reac- 
tion from taking place. Of late certain color reactions have 
become prominent. Mucin is coagulated into threads by 
alcohol or corrosive sublimate, and in this form can be 
stained by a number of staining reagents. Alum-hema- 
toxylin under certain conditions will stain mucin. Accord- 



HISTOLOGICAL METHODS. 357 

ing to P. Mayer, these conditions depend on a certain degree 
of ripeness of the solution, on the presence of enough alum 
to keep the nuclei from staining deeply, and, most important 
of all, on the absence of any free acid. This is difficult to 
manage, unless the solution is carefully neutralized, on ac- 
count of the acid properties of alum. Mayer therefore 
recommends staining the sections in muchematein (see 
page 243). 

Various aniline dyes have been recommended for staining 
mucin : those most favorably spoken of are methylene-blue 
(Orth), Bismarck brown (P. Mayer), thionin (Hoyer), poly- 
chrome methylene-blue (Unna), and toluidin-blue. The 
drawback to most of the aniline stains is that they are 
quickly extracted by the alcohol used for dehydrating. On 
this account P. Mayer highly recommends Bismarck brown, 
because permanent mounts can be easily made with it. It 
is not extracted by alcohol, and it does not fade in Canada 
balsam like many of the others. 

Hardening in corrosive sublimate and imbedding in pa- 
raffin are generally recommended as preferable to hardening 
in alcohol and imbedding in celloidin. Stain sections for 
five to fifteen minutes in a rather dilute aqueous solution of 
the dye chosen. Of Bismarck brown use a saturated aque- 
ous solution, and stain, if necessary, twenty-four hours. 
With thionin, toluidin-blue, and polychrome methylene-blue 
metachromatic stains are obtained ; the mucin is colored red, 
the rest of the tissue blue. Two special methods for stain- 
ing mucin are given in detail : 

Hoyer's Method with Thionin. — Mucin, red; everything 
else, blue. 1. Harden in corrosive sublimate, followed by 
alcohol. 

2. Paraffin sections are passed through xylol, chloroform, 
and 95 per cent, alcohol to free them from paraffin, and are 
then placed in a 5 per cent, aqueous solution of corrosive 
sublimate for three to five minutes. 

3. Stain in a dilute solution of thionin for ten to fifteen 
minutes. 

4. Alcohol. 



358 PATHOLOGICAL TECHNIQUE. 

5. Clear in the mixture of the oils of cloves and thyme. 

6. Turpentine oil or oil of cedar. 

7. Balsam. 

Before the staining the sections must not be treated with 
iodin solution to get rid of the precipitate of mercury, be- 
cause it spoils the staining. 

Unna's Method with Polychrome Methylene-blue. — 1. 
Stain paraffin or celloidin sections hardened in alcohol in 
polychrome methylene-blue five to ten minutes or longer. 

2. Wash in acidulated water. 

3. Fix in 10 per cent, solution of bichromate of potassium 
half a minute. 

4. Wash in water. 

5. Dry on slide with filter-paper. 

6. Decolorize in aniline plus 1 per cent, hydrochloric acid 
(a few seconds only). 

7. Wash off with oil of bergamot. 

8. Balsam. 

Pseudo-mucin dissolves in water to form a slimy material, 
and is precipitated from its solutions by alcohol in thread- 
like masses which are again soluble in water. It is not 
affected by acetic acid. Pseudo-mucin is found in certain 
ovarian and other tumors. 

Colloid and Hyaline. — The terms colloid and hyaline 
are not yet sharply limited to definite chemical substances. 
The term colloid was originally applied to the homogeneous 
substance found in the thyroid gland, but has been broad- 
ened to include various substances of a similar appearance. 
The term hyaline is still more indefinite, but its use may be 
said to be applied most generally to those homogeneous 
substances which stain deeply with various stains, in contra- 
distinction to those which like colloid show no marked af- 
finity for staining reagents after ordinary fixatives. 

Unquestionably, numerous substances of different chemi- 
cal composition and of varying origin have been grouped 
under these two titles because of their physical and optical 
characteristics — namely, that they occur as glassy, refractive, 
homogeneous, occasionally colored gelatinous or firm masses. 



HISTOLOGICAL METHODS. 359 

Chemically, very little that is definite is known about them, 
and they possess no peculiar chemical reactions. Several at- 
tempts have been made to classify them in accordance with 
their reactions to various staining reagents. 

Von Recklinghausen applied the term colloid to all the 
homogeneous, transparent-looking substances, including mu- 
cin, amyloid, etc., and reserved the term hyaline for a special 
group, which, according to him, is characterized by the fol- 
lowing peculiarities : it resembles amyloid in physical charac- 
teristics, but does not react to iodin ; it stains deeply with 
acid dyes, such as eosin and acid fuchsin. 

Ernst has recently endeavored to differentiate two groups 
of hyaline substances, colloid and hyaline, by means of their 
reaction to Van Gieson's picro-acid fuchsin solution. Ac- 
cording to him, true hyaline stains with acid fuchsin alone, 
and appears of a deep-red color, while colloid, of which the 
typical example is found in the thyroid gland, stains with 
both picric acid and acid fuchsin, so that it appears of an 
orange or yellowish-brown color. He has also tried to prove 
that all colloid is derived from epithelial cells, while all hya- 
line comes from connective tissue or from blood-vessels. 

According to Von Kahlden, these differential staining re- 
actions with Van Gieson's mixture claimed by Ernst for col- 
loid and hyaline are by no means justifiable, because true 
colloid often stains a deep red. Furthermore, Unna has 
shown that in the skin connective-tissue cells can give rise to 
the so-called true hyaline, of which part is acidophilic and 
part basophilic, while the intercellular substance gives rise to 
colloid. 

The last attempt to classify the various homogeneous sub- 
stances on the basis of their reactions to dyes, apparently 
the only method possible at present, has been made by 
Pianese as a result of his studies of the various degenerative 
processes occurring in cancer-cells. He used a special fixa- 
tive (see p. 225) and five different staining methods (see p. 
250, methods III. A and B, IV., V., and VI.). Of these 
methods, III. B is the best, because it gives a characteristic 
color to each substance — hyaline, brick-red ; colloid, bright 



360 PATHOLOGICAL TECHNIQUE. 

green ; mucin, clear sky-blue ; and a substance resembling 
amyloid, a dark reddish-violet. Besides these distinct re- 
actions for colloid, hyaline, mucin, and a substance resem- 
bling amyloid, he found others less definite ; one of these he 
calls pseudo-mucin and another pseudo-colloid. As a basis 
for his studies he took the reactions of amyloid, mucin (in- 
testine), colloid (thyroid gland), and hyaline (hyaline remains 
of ovarian follicles, hyaline degeneration of renal glomeru- 
li), with the same stains after fixation in his own hardening 
mixture. 

The above brief historical statement is considered neces- 
sary to show the present views in regard to these various, 
more or less indefinite, homogeneous, transparent substances. 
For demonstrating them after the usual hardening reagents, 
of which alcohol and corrosive sublimate are perhaps the 
best, a double stain with alum-hematoxylin and eosin is very 
useful. Certain of the homogeneous substances stain deeply 
with eosin ; others, like the transparent drops and masses oc- 
casionally found in the walls of the blood-vessels of the 
brain, stain with hematoxylin. Sometimes good results can 
be obtained with Weigert's fibrin stain or with carbol-fuch- 
sin. The most generally useful stain, aside from alum-hema- 
toxylin and eosin, is probably Van Gieson's mixture. 

1. Stain deeply in alum-hematoxylin. 

2. Wash in water. 

3. Stain three to five minutes in a saturated aqueous solu- 
tion of picric acid, to which is added enough of a saturated 
aqueous solution of acid fuchsin to give it a deep-red color. 
The effect of various proportions is sometimes useful. 

4. Wash in water. 

5. Alcohol. 

6. Oleum origani cretici. 

7. Balsam. 

The transparent homogeneous substances usually stain 
from orange to deep red in color; connective tissue, red. 

Unna's Method for Hyaline and Colloid Material. — A. 
Harden in alcohol. 1. Acid fuchsin (2 per cent, aqueous 
solution) five minutes. 



HISTOLOGICAL METHODS. 36 1 

2. Saturated aqueous solution of picric acid two minutes. 

3. Saturated alcoholic solution of picric acid two minutes. 

4. Wash off in alcohol. 

5. Oil, balsam. 

Hyaline and connective-tissue fibers, red; colloid of thy- 
roid gland, yellow ; protoplasm, yellow. 

B. To show acidophilic and basophilic hyaline: 1. Water- 
blue (2 per cent, aqueous solution) twenty to thirty seconds. 

2. Water. 

3. Carbol-fuchsin one to two minutes. 

4. Water. 

5. Alcohol slightly tinged with iodin. 

6. Pure alcohol. 

7. Oil, balsam. 

Nuclei, keratin, and large hyaline masses, cherry red ; con- 
nective-tissue fibrillar, protoplasm, and small hyaline bodies, 
blue. 

For finer work the methods of Pianese should be used. 

Keratohyalin (Unnd). — 1. Stain sections in a fairly old 
alum-hematoxylin solution until they are over-stained. 

2. Place in a very weak solution of permanganate of 
potassium (about 1 : 2000) for ten seconds. 

3. Dehydrate and decolorize in alcohol. 

4. Oil, balsam. 

An isolated stain of the granules of keratohyalin is ob- 
tained, blue-black in color. 

In like manner a 33 per cent, solution of sulphate of iron 
acting for ten minutes, or a 10 per cent, solution of chlorid 
of iron for a few seconds, will produce the same effect. Or- 
dinarily, sections are stained deeply in alum-hematoxylin, 
and decolorized with acetic acid and alcohol or with hydro- 
chloric acid and alcohol. 

Glycogen Infiltration. — Glycogen is a carbohydrate 
of slightly varying composition, occurring in cells, more 
rarely in the intercellular tissue, either diffusely or more 
commonly in the form of larger and smaller masses and 
granules of a transparent homogeneous appearance. It is 
demonstrated micro-chemically by means of its reaction with 



362 PATHOLOGICAL TECHNIQUE. 

iodin, which stains it brown. It is easily differentiated from 
amyloid by the fact that with the exception of the glycogen 
from certain sources, such as cartilage-cells, it is readily 
soluble in water and does not give the iodin-sulphuric-acid 
reaction. 

In consequence of its property of dissolving readily in 
water the aqueous Lugol's solution of iodin cannot be em- 
ployed for staining glycogen in fresh tissues. Instead, a 
thick solution of gum arabic containing 1 per cent, of Lugol's 
solution must be used, or, better still, equal parts of glycerin 
and Lugol's solution, in which the sections are more per- 
fectly cleared. 

For sections hardened in absolute alcohol the same 
methods may be used, but better results, and practically 
permanent mounts, can be obtained by the method of Lang- 
hans. Lugol's solution is used for staining the sections, be- 
cause after hardening in alcohol the glycogen is much less 
soluble in water than in the fresh state. The iodin-glycerin 
mixture would probably be better. 

1. Stain in Lugol's solution. 

2. Dehydrate in 1 part of tincture of iodin to 3 or 4 parts 
of absolute alcohol. 

3. Clear in oleum origani cretici. 

The sections are to be preserved in oil. Even a ring of 
balsam around the cover-slip will cause the color to fade. 
Other oils are not so good. 

Amyloid Infiltration. — Amyloid is insoluble in water, 
alcohol, ether, and dilute acids, and is not digested by pepsin 
and hydrochloric acid. It is distinguished from the other 
homogeneous substances, except glycogen, by the fact that 
it is stained mahogany-brown by iodin in solution. If a 
section containing amyloid be quickly and lightly stained in 
iodin solution and then transferred to sulphuric acid, the 
color of the amyloid will usually change at once or in a few 
minutes from red, through violet, to blue. Sometimes the 
color turns simply of a deeper brown. Several of the 
aniline dyes give almost as perfect characteristic color-reac- 
tions for amyloid as iodin, and are perhaps better for the 



HISTOLOGICAL METHODS. 363 

purposes of histological study. Any of these differential 
stains may be used with fresh or hardened tissues. Alcohol 
as a hardening reagent gives the best results, but the other 
fixatives may be employed. Unfortunately, good permanent 
mounts cannot be made with any of the characteristic stains, 
so that the ordinary double stains of alum-hematoxylin with 
eosin or Van Gieson's mixture will often be found of the 
greatest help in studying the distribution of amyloid. 

Iodin Reaction for Amyloid. — 1. Stain sections in a weak 
solution of iodin (Lugol's solution diluted until of a clear 
yellow color) for three minutes. 

2. Wash in water. 

3. Mount and examine in water or glycerin. 

If the tissue reacts strongly alkaline, a condition which 
may result from post-mortem decomposition, the color reac- 
tion with iodin will not take place. In such cases the tissue 
or the sections of it should be treated with dilute acetic acid 
before applying the test. The normal reaction of amyloid 
with iodin may be increased by treating the section after 
staining with dilute acetic acid. 

Langhans' Method for Obtaining 1 Permanent Mounts 
with Iodin. — 1. Harden in alcohol. 

2. Stain sections in Lugol's solution. 

3. Dehyhrate in 1 part of tincture of iodin to 3 or 4 parts 
of absolute alcohol. 

4. Clear and mount in oleum origani cretici. 

The color is said to keep remarkably well. Other oils or 
balsam cause it to fade quickly. The staining in Lugol's 
solution may be omitted, as the tincture of iodin usually 
stains the amyloid sufficiently deeply. 

Iodin and Sulphuric-acid Reaction. — 1. Stain quickly 
and lightly in dilute Lugol's solution. 

2. Treat with sulphuric acid, either concentrated or dilute 
(1 to 5 per cent), on the slide or in the staining dish. Strong 
hydrochloric acid may be used in the same way. 

The change of colors from red to blue already spoken of 
usually occurs within a few minutes, but occasionally does 
not take place at all. 



364 PATHOLOGICAL TECHNIQUE. 

The following substances give reactions with the above 
iodin tests : 

1. Cholesterin crystals are stained rather dark with dilute 
iodin solution, and turn a beautiful blue color at the edges 
on the addition of strong sulphuric acid. 

2. The corpora amylacea in the prostate and central nerv- 
ous system stain brown with the dilute iodin solution. 

3. Starch-granules stain blue with dilute iodin solution. 

4. Cellulose stains yellow with iodin. If washed and 
treated with strong sulphuric acid, it turns blue where the 
acid touchs it. 

For the reactions with the aniline dyes the sections must 
be free from celloidin. 

Reaction with Methyl- or Gentian- violet. — 1. Stain in 
1 per cent, methyl- violet three to five minutes. 

2. Wash in water plus 1 per cent, of hydrochloric acid. 

3. Examine in water or in glycerin. 

The stain will keep for some time if mounted in a satu- 
rated solution of acetate of potash or in levulose. Other 
methods are to stain in aniline-gentian-violet and to wash 
out in a 1 or 2 per cent, solution of acetic acid, or to stain 
in a strong solution of methyl-violet to which acetic acid is 
added, and to wash out in water. The amyloid is stained 
violet-red, the tissue blue. 

Reaction with Iodin-green. — 1. Stain fresh or hardened 
sections in a J per cent, aqueous solution of iodin-green for 
twenty-four hours. 

2. Wash in water. 

3. Mount in water or glycerin. 

Amyloid, a violet-red ; tissue, green. Stilling claims that 
the reaction is surer than with methyl-violet. 

Reaction with Bismarck Brown and Gentian-violet 
(Birch-Hirschfeld). — 1. Stain in a 2 per cent, alcoholic solu- 
tion of Bismarck brown five minutes. 

2. Wash in absolute alcohol. 

3. Wash in distilled water ten minutes. 

4. Stain in a 2 per cent, solution of gentian-violet five to 
ten minutes. 



HISTOLOGICAL METHODS. 365 

5. Wash in dilute acetic-acid solution. 

6. Mount in levulose. 
Amyloid, red ; tissue, brown. 

Pigmentation. — The various pigments found in the 
human body under normal and pathological conditions may 
be divided into three groups : 

1. Hematogenous pigments, derived from the coloring 
matter of the blood. 

(a) Hemoglobin and methetnoglobin : soluble in water and 
alcohol not absolute ; occur as yellowish to yellowish-brown 
granules and droplets ; stain deeply with eosin after proper 
fixation ; occur in hemoglobinuria, etc. 

ip) Parhemoglobin : a form of hemoglobin ; crystallizes 
like it, but is insoluble in alcohol. 

(c) Hematoidin=bilirubin : contains no iron ; is insoluble 
in water, alcohol, and ether ; dissolves in chloroform ; oc- 
curs as yellow or brown amorphous material or as crys- 
talline rhombic plates and needles. Is found in extravasa- 
tions of blood. 

(d) Hemosiderin : occurs as bright-colored, yellowish- 
brown and brown granules and masses ; gives iron reac- 
tion ; is insoluble in water, alcohol, and ether ; is found 
in extravasations of blood, in the liver in pernicious 
anemia, etc. 

(e) Melanin : occurs as dark-brown or black granules and 
masses ; does not give iron reaction ; is found in malaria in 
the red blood-globules and in the tissues of the spleen, liver, 
and brain, but not of the lungs. 

(/") Bile-pig ment=bilirnbin=hematoidin : insoluble in water, 
ether, and alcohol ; occurs as yellowish granules and masses 
which are often greenish if old ; is found in jaundice. 

2. Autochthonous pigments, formed by cells from color- 
less elements of nutrition. They all occur microscopically as 
lighter or darker brown granules ; are insoluble in water, 
alcohol, dilute caustic potash, etc., and contain no iron. 
They are found in the iris, retina, skin, ganglion-cells, Addi- 
son's disease, melanotic sarcomata, etc. 

3. Extraneous pigments, entering the body from with- 



366 PATHOLOGICAL TECHNIQUE. 

out. The most common examples are carbon in anthra- 
cosis pulmonum, iron in siderosis pulmonum, silver in 
argyria. 

Pigments are recognized microscopically, partly by their 
color and form, partly by their chemical reactions, and partly, 
though less accurately, by the lesions or pathological pro- 
cesses in connection with which they occur. They usually 
show best in contrast to red nuclear stains, such as alum or 
lithium carmine, but alum-hematoxylin often gives excellent 
results. 

The pigments of the second and third groups are perfectly 
preserved by all of the ordinary fixatives, of which alcohol, 
corrosive sublimate, and Zenker's fluid can be particularly 
recommended. Of the first group, melanin and hematoidin 
are preserved in any fixative. Hemoglobin and methemo- 
globin must be fixed in the solutions recommended for red 
blood-globules — namely, Zenker's fluid, corrosive sublimate, 
and Miiller's fluid. Parhemoglobin and hemosiderin should 
be preserved in alcohol. Bile-pigment is turned green, accord- 
ing to Ziegler, by fixation in corrosive sublimate, and is 
thereby rendered more prominent. In alcohol it preserves 
its yellow color. 

Carbon may be distinguished from melanin or any of the 
other pigments by the fact that it is insoluble in concentrated 
sulphuric acid. The only pigment for which micro-chemical 
color reactions are generally employed is hemosiderin, which 
really represents a group of pigments containing iron instead 
of one definite compound. Most of them will show the iron 
reaction after a shorter or longer time, but others, like the 
hemoglobin from which they are all derived, refuse to give it. 

The iron compounds present are usually ferric salts, but 
occasionally ferrous. Both groups react in the same way 
to sulphate of ammonium, but only the ferric salts react to 
ferrocyanide of potassium. For the ferrous salts, which oc- 
cur much more rarely, the ferricyanide of potassium must be 
used. Dr. E. S. Wood suggests that a mixture of ferro- and 
ferricyanide of potassium be employed, so as to demonstrate 
at once both groups of iron compounds, as with the sulphate- 



HISTOLOGICAL METHODS. 367 

of-ammonium method. In performing the iron reactions steel 
needles must be avoided. 

Reactions for Iron in Hemosiderin. — Tissues should be 
hardened in alcohol. I. Reaction for ferric salts with ferro- 
cyanide of potassium and hydrochloric acid. 

A. 1. Place sections for 'five to twenty minutes or longer in 
a 2 per cent, aqueous solution of ferrocyanide of potassium. 

2. Transfer to acid alcohol (HC1 1 c.c. to 70 per cent, al- 
cohol 100 c.c.) for five to ten minutes, or to glycerin plus \ 
per cent, hydrochloric acid. The iron appears bright blue in 
color. 

If desired, the sections can be washed out after the acid al- 
cohol, and passed through alcohol and oil to balsam. After 
the iron reaction has been performed the nuclei may be 
stained in either alum or lithium carmine, or a little ferrocy- 
anide of potassium may be added to the lithium carmine, and 
the reaction and nuclear stain thus effected by the same step. 

B. H. Stieda's Method for Permanent Mounts with Nuclear 
Stains. — 1. Stain several hours in lithium carmine. 

2. Wash off quickly in water. 

3. Place from four to six hours in a 2 per cent, aqueous 
solution of ferrocyanide of potassium. 

4. Transfer to acid alcohol for six to twelve hours. 

5. Wash quickly in water. 

6. Alcohol, oil, Canada balsam. 

II. The reaction for the ferrous salts is performed in the 
same way as for ferric salts, with the exception that ferri- 
cyanide of potassium is used instead of the ferro- compound. 

III. Reactions for Ferric and Ferrous Salts. — A. Use a 
mixture of ferro- and ferricyanide of potassium (1 gram each 
to 100 c.c. of water), followed by acid alcohol. Nuclear 
stains and permanent mounts may be made as above. 

B. 1. Place sections in a freshly prepared solution of sul- 
phate of ammonium for five to twenty minutes, until they 
are dark or black-green in color. 

2. Wash quickly in water. 

3. Examine in glycerin or pass through alcohol and oil to 
Canada balsam. 



368 PATHOLOGICAL TECHNIQUE. 

The iron appears in the form of black or dark-greenish 
granules. Sulphate of ammonium causes similar precipi- 
tates with other metal salts, such as the nitrates of silver, 
lead, and mercury. 

Petrifaction. — Calcification, the more common form of 
petrifaction, is the term applied to the infiltration of tissues 
with phosphate and carbonate of lime. The salts appear 
microscopically as small, very refractive granules which may 
be mistaken for fat, or as large masses due to the fusion of 
granules. They are dissolved by hydrochloric or nitric acid 
(5 per cent, solution). If carbonate of lime is present, bubbles 
of carbon-dioxid are set free. Phosphate of lime dissolves 
without effervescence. To differentiate between lime-salts 
and other substances soluble in hydrochloric acid use con- 
centrated sulphuric acid to form sulphate of lime (gypsum), 
which appears as fine, short, radiating needles. On dissolv- 
ing out the lime-salts a matrix of dead tissue or of hyaline 
material will usually be found left behind. As a rule, this 
hyaline material stains deep blue in alum-hematoxylin or red 
in Van Gieson's mixture. 

Another form of petrifaction is that found in gout, due to 
the infiltration of certain tissues with uric-acid salts, of which 
urate of sodium is the most common. The crystals are sol- 
uble with difficulty in cold water, insoluble in alcohol and 
ether. 



CLINICAL PATHOLOGY. 

The material received at the pathological laboratory from 
clinical cases consists largely of new growths and lesions 
produced by infectious, chemical, or traumatic agents — to a 
less extent of fluids from various natural or artificial cavities 
or secretions and eliminations from the respiratory, genito- 
urinary, and gastro-intestinal tracts. In the following pages 
a brief synopsis is given of what may be expected in the 
various fluids and eliminations, and the more important 
chemical tests required for the recognition of certain sub- 
stances are added. 



HISTOLOGICAL METHODS. 369 

Gross specimens removed at operations should be treated 
as parts of autopsies, and dissected or otherwise examined 
bacteriologically and histologically in an equally careful 
manner. For the finer study of cancers and other new 
growths the recently published methods of Pianese should 
be employed (see page 250). 

Examination of Tissues from Clinical Cases for 
Diagnosis. — Tumors of any size or large pieces of tissue 
present no difficulties. There is plenty of material to ex- 
amine fresh or after fixing in a variety of ways. The small 
bits removed with a Mixter punch or cut from the edge of a 
growth, of which a diagnosis is wanted immediately, some- 
times prove troublesome. Frozen sections of the fresh 
tissue are often sufficient. Sometimes it is better to harden 
for an hour or more in formaldehyde and then to make 
frozen sections. Often it is wisest to harden in strong alco- 
hol and then to make razor sections or to imbed in celloidin. 
The whole process of hardening, imbedding, and sectioning 
can easily be carried through in twenty-four hours with 
small pieces of tissue. Imbedding in paraffin is sometimes 
preferred. In cutting sections of small pieces it is important 
to mount them if possible, so that the cut sections will show 
proper relations — i. e. vertical sections through the skin, 
uterine mucous membrane, etc. — otherwise confusing pict- 
ures will often be presented. It is important to know, in 
regard to pieces of tissue sent for diagnosis, from what part 
of the body they come, because what is normal in one situa- 
tion may be pathological in another. 

A hematoxylin-and-eosin stain will be found the most 
generally useful for hardened sections. 

Uterine Scrapings. — Small pieces may be examined 
fresh in frozen sections or after hardening for one or more 
hours in formaldehyde. Better results are obtained by hard- 
ening in alcohol and imbedding in celloidin or paraffin. 
Where the fragments are small, it is advisable to mass them 
together on a small piece of filter-paper and to harden in 
strong alcohol. The mass can then be imbedded in celloidin 
and cut as one piece of tissue. A hematoxylin-and-eosin 

24 



370 PATHOLOGICAL TECHNIQUE. 

stain is the best, because the eosin brings out the smooth 
muscle-fibers prominently, so that any invasion of the mus- 
cular coat by a malignant growth is more readily made out 
— a valuable help in the diagnosis of malignant adenoma. 

Examination of Fluids obtained by Puncture. — 
The transudations obtained largely from the serous cav- 
ities are non-inflammatory in origin. They are usually of a 
transparent, pale-yellow color with slightly greenish tint, 
alkaline in reaction, and deposit on standing a slight floccu- 
lent coagulum. 

The specific gravity, to be taken at room-temperature, 
varies according to the origin of the fluid. According to 
Reuss, it is below 1015 in hydrothorax; below 1012 in 
ascites; below 1010 in anasarca; below 1008.5 in hydro- 
thorax. 

The amount of albumin in hydrothorax is always under 
2.5 per cent., and in ascites between 1.5 and 2 per cent. 
Microscopically, a .few leucocytes, usually fatty degenerated 
and rarely desquamated endothelial cells, are found. 

The exudations are of inflammatory origin, and are also 
generally obtained from the serous cavities. From their 
various microscopic appearances they are divided into serous 
(fibrino-serous), hemorrhagic, purulent, and gangrenous. 
The specific gravity of all is over 1018 ; the reaction is always 
alkaline. On standing they deposit a varying amount of 
sediment. Examinations for organisms should always be 
made (see page 89). Occasionally a peculiar opalescent 
layer, due to cholesterin crystals, forms on the surface of 
fluids which come from old cases of pleurisy. 

Serous Exudations. — The fluid, which immediately after 
removal is slightly cloudy and yellowish in color, deposits 
more or less quickly a flocculent or dense coagulum. Micro- 
scopically, the coagulum shows a dense meshwork of fibrin 
and numerous polynuclear leucocytes. 

Hemorrhagic Exudations. — The sero-fibrinous exudation 
is colored a lighter or darker red according to the amount 
of blood present. Microscopically, the same elements are 
found as in the serous exudations, plus a marked increase 



HISTOLOGICAL METHODS. 37 1 

of red blood-globules, which are usually well preserved, but 
in old exudations may be more or less decolorized. 

Aside from injuries, hemorrhagic exudations are most com- 
mon in connection with tuberculosis and new growths, so 
that their microscopic examination is of much diagnostic 
and prognostic value. 

For the examination of tubercle bacilli see page 91. In 
this form of exudation it is rarely possible to demonstrate 
them. On the other hand, it is not infrequently possible to 
make the diagnosis of a malignant growth, especially of 
cancer, from the examination of the sediment. No cell is 
significant of cancer or other neoplasm, but the occurrence 
of numerous cells which vary greatly in form is suspicious. 
The cells from new growths are often unusually large, up to 
120/i, frequently contain one or more vacuoles, and usually 
lie in clumps. Large drops of fat are also considered sus- 
picious. 

A positive diagnosis can only be made by obtaining bits 
of tissue which show the structure of the new growth, such 
as the atypical alveolar arrangement of the cells in cancer. 

Purulent exudations appear more or less thick and yel- 
low, and deposit a corresponding layer of pus. Microscopic- 
ally, they present no peculiarities other than the organisms 
to which they are due. Among the etiological factors acti- 
nomyces must always be thought of in puzzling cases. 

Putrid exudations occur in the pleural and peritoneal 
cavities in consequence of gangrenous masses breaking into 
them and from stomach or intestinal ulcerations, from new 
growths, occasionally from no clear cause. The fluid result- 
ing from the perforation of a gastric ulcer may show yeast- 
cells and sarcinae, and give an acid reaction. 

I/Umbar Puncture. — The diagnostic value of lumbar 
puncture has been sufficiently demonstrated. Not only is 
it possible to diagnosticate inflammation of the meninges, 
but the character and cause of the inflammation may usually 
be demonstrated if the examination of the fluid is properly 
performed. In a number of cases of general infection in 
which there was no inflammation of the meninges a diag- 



372 PATHOLOGICAL TECHNIQUE. 

nosis has been made by means of cultures taken from the 
cerebro-spinal fluid. Finally, a number of cases of hemor- 
rhage into the brain and spinal canal have been diagnosticated 
by lumbar puncture. 

The operation and the subsequent examination of the fluid 
should be as carefully performed as any other bacteriological 
investigation in order to obtain accurate results. The back 
of the patient and the operator's hands should be made 
sterile. The needle should be boiled for ten minutes. The 
patient should lie on the right side, with the knees drawn up, 
and with the uppermost shoulder so depressed as to present 
the spinal column to the operator. This position permits the 
operator to thrust the needle directly forward rather than 
from the side. An antitoxin needle 4 cm. in length, with a 
diameter of 1 mm., is well adapted for infants and young 
children. A longer needle is necessary for adults and chil- 
dren over ten years of age. 

Aspiration of the fluid is not necessary, but some ope- 
rators prefer to attach a hypodermic syringe to the needle to 
afford a better grasp for the hand. In this case the syringe 
would have to be detached to allow the fluid to flow. The 
additional manipulation, and possibly the defective steriliza- 
tion of the syringe, might impair the subsequent bacterio- 
logical examination. 

The puncture is generally made between the third and 
the fourth lumbar vertebrae ; sometimes between the second 
and third. The thumb of the left hand is pressed between 
the spinous processes, and the point of the needle is entered 
about 1 cm. to the right of the median line and on a level 
with the thumb-nail, and directed slightly upward and in- 
ward toward the median line. Care must be exercised to 
prevent the point of the needle from passing to the left of 
the median line and striking on the bone. At a depth of 3 
or 4 cm. in children and 7 or 8 cm. in adults the needle en- 
ters the subarachnoid space, and the fluid flows usually by 
drops. If the point of the needle meets with a bony obstruc- 
tion, it is advisable to withdraw the needle somewhat, and to 
thrust again, directing the point of the needle toward the 



HISTOLOGICAL METHODS. 373 

median line, rather than to make lateral movements, with the 
danger of breaking the needle or causing a hemorrhage. 
The smallest quantity of blood obscures the macroscopic 
appearance of the fluid by rendering it cloudy. The fluid is 
allowed to drop into an absolutely clean test-tube which pre- 
viously has been sterilized by dry heat to 150 C. and stop- 
pered with cotton. The fluid should be allowed to drop into 
the tube without running down the sides. From 5 to 1 5 c.c. 
of fluid is a sufficient quantity for examination. 

Cultures on blood-serum should be made at once from the 
fluid. The test-tube is then held toward the light and gently 
shaken; by this means the slightest cloudiness can be de- 
tected. 

In meningitis there is always an exudation of cells which 
makes the fluid more or less cloudy. The degree of cloudi- 
ness is to some extent proportionate to the amount and cha- 
racter of the exudation. In tubercular meningitis the amount 
of cellular exudation is sometimes so slight that the fluid ap- 
pears clear unless examined carefully. A guinea-pig should 
be inoculated with some of the fluid as a control-experiment. 
The inoculation should be made a short time after withdraw- 
ing the fluid before the formation of fibrin occurs, because the 
web-like coagulum of fibrin holds the tubercle bacilli in its 
meshes. After standing for several hours more or less fibrin 
forms in the fluid, and contains the cells in its meshes. The 
supernatant fluid is left clear. Cover-glass preparations should 
be made from this sediment, dried by passing through the 
flame of an alcohol lamp or Bunsen burner, and stained with 
methylene-blue, which stains the nuclei of the cells and any 
pathogenic bacteria which may be present. 

In tubercular meningitis the predominant cell is the lymph- 
oid cell. In purulent meningitis the polynuclear leucocyte 
predominates. Cover-glass preparations may also be stained 
for tubercle bacilli by appropriate methods of staining. 

It is often necessary to examine twenty or more prepara- 
tions, however, before finding the bacilli. The albumin 
should be quantitated. Normally, the cerebro-spinal fluid 
contains from ^ to y^- of 1 per cent, or less. In menin- 



374 PATHOLOGICAL TECHNIQUE. 

gitis the amount is increased from -^ to -^ of i per cent., or 
often more. Percentages of albumin down to yj-g- of I per 
cent, can be estimated by the ferrocyanide-of-potassium-and 
acetic-acid test and a centrifugal machine. Take 3 \ c.c. of 
a 20 per cent, solution of ferrocyanide of potassium, \\ c.c. 
of acetic acid, and 10 c.c. of the fluid in which the albumin 
is to be quantitated. The mixture of reagents and fluid is 
poured into a conically-shaped graduated glass vessel de- 
signed for the purpose and centrifugalized. Sugar is rarely 
present and has no diagnostic value. 

Ovarian and Parovarian Cysts. — The simple cysts of 
the ovary due to distention of Graafian follicles or to cystic 
change of corpora lutea, and the parovarian cysts contain a 
thin, clear, serous fluid of low specific gravity. 

The contents of the multilocular and papillary adeno-cys- 
tomata of the ovary are usually tenacious and mucous, of 
very varying specific gravity, from 1005-1050, but usually 
between 1020 and 1024. The fluid generally contains much 
albumin and is rich in metalbumin, which is precipitated by 
alcohol, but not by acetic acid, nitric acid, or boiling, so that 
it can readily be distinguished from mucin. Before making 
the test the albumin must be removed. 

The cyst-contents are usually yellowish, but sometimes 
may be dark-red or chocolate-colored. Microscopically, 
red and white blood-globules, occasionally blood-pigment 
and cholesterin crystals, often fat-granules and large vacu- 
olated cells, are found in the cyst fluid. Bizzozero considers 
cylindrical epithelial cells, ciliated and beaker cells, and col- 
loid concretions especially important from a diagnostic point 
of view. 

Pancreatic Cyst or Fistula.— The fluid obtained from 
a permanent fistula or large cyst of the pancreas contains 
much less solids than the normal pancreatic juice, and the 
trypsin ferment may be present in very small amount or 
possibly be entirely wanting. The fluid is colorless, alkaline 
in reaction, and has a specific gravity of about ion. It is 
characterized by three distinct properties on which its re- 
cognition depends — namely : 



HISTOLOGICAL METHODS. 375 

1. It splits up fat into fatty acids and glycerin. Mix to- 
gether equal parts of neutral olive oil and the alkaline fluid. 
Test with litmus-paper. Place the mixture in the incubator 
at 37 C, and test from time to time. If the fluid is pan- 
creatic, an acid reaction will be obtained in twelve to eighteen 
minutes. 

2. It transforms starch into sugar. Place in the incubator 
equal parts of a 1 per cent, aqueous solution of starch and 
of the fluid to be tested. In ten to twenty minutes test for 
sugar with Fehling's solution. 

3. It digests fibrin in an alkaline solution (trypsin ferment). 
Place some fibrin in the alkaline fluid and set it in the in- 
cubator. In one-half to one hour examine for peptones 
by the biuret test. Add caustic potash or soda and a few 
drops of a dilute solution of sulphate of copper. If 
peptones are present, a beautiful reddish-violet color will 
be produced. 

Dropsy of the Gall-bladder. — Puncture is generally 
not advisable. The fluid is usually colorless and mucoid or 
serous in character. All trace of biliary constituents may 
have disappeared. According to Lenhartz, numerous colon 
bacilli are usually present. 

Hydronephrosis and Renal Cysts. — The fluid is 
almost always clear as water, rarely reddish or yellow. 
Specific gravity always under 1020 (usually between 10 10 
and 1015). Urea and uric acid are generally present, but 
may be absent. (Small amounts of urea are sometimes 
present in ovarian cysts.) Albumin is slight in amount. 
Microscopically, almost nothing is found. 

Bchinococcus Cysts. — The fluid is perfectly clear, free 
from albumin, and contains a little succinic acid and much 
chlorid of sodium. The specific gravity varies between 1008 
and 1013. 

Microscopically, often no traces of morphological ele- 
ments can be found. Occasionally, however, hemosiderin 
granules or chlolesterin crystals occur, or the characteristic 
structures from which a positive diagnosis can be made — - 
namely, scolices, hooklets, or pieces of cyst-membrane. 



376 PATHOLOGICAL TECHNIQUE. 

A positive diagnosis from a chemical examination depends 
on showing — 

1. The absence of albumin. 

2. The presence of chlorid of sodium. 

Evaporate a drop of the fluid slowly on a slide, so as to 
get the characteristic crystals of chlorid of sodium. 

3. The presence of succinic acid. 

Acidify a little of the fluid with hydrochloric acid and 
evaporate to dryness. Extract the residue with ether. The 
crystallized material left on the evaporation of the ether, if 
dissolved in water, will give a rust-colored, gelatinous pre- 
cipitate with sesquichlorid of iron if succinic acid be present. 

Examination of the Sputum. — The secretion raised 
from the air-passages by coughing is almost invariably con- 
taminated with the secretion of the naso-pharynx and with 
particles of food from the mouth. In examinations of 
sputum these contaminations must always be borne in mind. 
The amount raised varies from a few c.c. to one or even 
several liters in twenty-four hours. 

The macroscopic appearances of the sputum depend on 
the varying proportions of mucus, pus, blood, and serum 
present. The tenacity is mainly due to the mucus. The 
reaction is usually alkaline. 

The general color, consistency, and separation into layers 
is best seen after the sputum has stood for some time in a 
tall glass. For more careful macroscopic examination small 
portions of the sputum are transferred to flat glass dishes, 
where they are spread out thinly by needles and examined 
over black or white paper. Porcelain plates painted black or 
black paper itself can be used. The latter method is con- 
venient, because the sputum can be burned up with the paper. 

The constituents of the sputum which may be recognized 
macroscopically are few in number, and not so important as 
those which may be found microscopically. 

Macroscopic Examination. — 1. Caseous Masses. — In the 
sputum from tubercular cases small, opaque, yellowish-white 
masses from the size of a pin-head to that of a small pea 
can occasionally be found, which spread out beneath a, 



HISTOLOGICAL METHODS. 



377 



cover-glass like a bit of cheese. They are small caseous 
masses which are valuable for microscopic examination be- 
cause they usually contain tubercle bacilli and elastic fibers. 

2. Fibrinous casts of the bronchioles can usually be found 
in the sputum from the third to the seventh day in cases of 
acute lobar pneumonia. They appear as yellowish-white or 
reddish-yellow threads, 2 to 3 mm. thick and \ to several 
cm. long, and are often branched. The large ones are often 
rolled into balls, and show best after being shaken in water. 
Casts of the bronchi are found in cases of fibrinous bronchitis. 

3. Curschmann 's spirals (Fig. 103) of twisted threads of 




«*v 



WW 

mm 



Fig. 103. — Curschmann's spirals : a, central fiber. 

mucus enclosing epithelial cells and leucocytes occur rarely 
except in bronchial asthma. They appear macroscopically 
as grayish-white or whitish-yellow masses or threads, | to 1 \ 
mm. thick and J to 8 cm. long, and often show a visible 
spiral arrangement. 

4. Dittrictis Plugs. — These are whitish-yellow masses from 
the size of a pinhead to that of a bean, which are formed in 
cases of putrid bronchitis and of gangrene of the lung. 
They have a very fetid odor, a cheesy consistency, and are 
rather easily compressed. Besides organisms they contain 
numerous fat-crystals. 

5. Shreds of tissue are found almost solely in gangrene of 
the lung, and are best recognized with the microscope. . 

6. Concretions, portions of cysticercus membrane, etc. are 
rare in the secretion from the lungs. 



378 PATHOLOGICAL TECHNIQUE. 

Microscopic Examination. — Microscopically, the sputum 
may show various kinds of cells, fragments of tissue, includ- 
ing elastic fibers, vegetable and animal parasites, and crystals. 

They will be taken up in order : 

1. Red Blood-globules. — In fresh hemorrhages they appear 
normal, often in rouleaux. In old sputa many have lost 
their color. 

2. White blood-globules are almost invariably polynuclear, 
and the majority of them contain neutrophilic granules. In 
asthma, however, numerous eosinophilic and rather numer- 
ous basophilic leucocytes are regularly found. The leuco- 
cytes often contain pigment- or fat-granules. 

3. Epithelial Cells. — Pavement, cylindrical, and ciliated 
cells are found. The first come from the naso-pharynx ; the 
others usually from the trachea and bronchi, but may come 
from the nose. Desquamated alveolar epithelium is difficult 
to demonstrate. The pigmented cells found almost wholly 
in chronic passive congestion of the lungs are in small part 
alveolar epithelium, in larger part leucocytes. The pigment 
appears as yellowish, yellowish-red, or brownish-red granules 
or as yellow diffuse pigmentation. Occasionally, however, 
it is black, and then is less easily distinguished from carbon. 
The pigment is derived from the blood, and will usually give 
the iron reaction (see page 367), but very young or old pig- 
ment will not. 

4. Fatty Detritus. — Fat-drops are frequently found, due to 
the fatty degeneration of cells. 

5. Elastic fibers (Fig. 104) occur singly, but more often as 
a network. They are recognized by their sharp, dark out- 
lines, due to their high degree of refractiveness, and by their 
marked degree of resistance to acids and alkalies by which 
other like tissues, such as connective-tissue fibers, are de- 
stroyed. Elastic fibers are most abundant in the caseous 
masses above mentioned. When these masses cannot be 
found, the thicker portions of the sputum are squeezed be- 
tween a slide and cover-glass or between two slides, and ex- 
amined with a low power, The examination is rendered 
easier by mixing a little sputum with a 10 per cent, solution 






HISTOLOGICAL METHODS. 379 

of caustic potash or soda. In certain cases it is necessary 
to mix together equal parts of the sputum and 10 per cent, 
caustic potash or soda, and to boil the mixture until the 
sputum is dissolved. The solution is then mixed with four 
times its own volume of water and allowed to stand for 
twenty-four hours, when the sediment can be examined for 
the elastic fibers. 

Vegetable and Animal Parasites. — Of the vegetable 
parasites, the most important is the tubercle bacillus (for its 
examination see page 91). Other bacteria sometimes ex- 
amined for are the pneumococcus, the influenza bacillus, and 
actinomyces. 

Of the animal parasites, the ameba coli is sometimes 




Fig. 104. — Elastic fibers (after Striimpell). 

found secondary to an hepatic abscess which has perforated 
into the lung (see page 292). Portions of the membrane of 
an echinococcus cyst or the hooklets from the head may be 
found in the sputum, but infection with this parasite is very 
rare in this country. 

Of the crystals which occur in sputa, the most important 
are the Charcot-Leyden crystals, found mainly in bronchial 
asthma, and the crystals of the fatty acids, of cholesterin, 
and of hematoidin. Tyrosin and leucin are much more rare. 

The Charcot-Leyden crystals are colorless, elongated 
octahedra of varying size, soluble with difficulty in cold 
water, insoluble in alcohol, ether, chloroform, and dilute 
saline solution. 

Hematoidin crystals occur as ruby-red rhombic plates or 
columns. 



3 8o 



PA THOL GICA L TE CHNIQ UE. 



Cholesterin crystals (Fig. 105) occur as the well-known 
small and large rhombic plates. 

The fatty-acid crystals occur as long, pointed needles, 
either singly or in groups. They are easily soluble in ether 
or hot alcohol, insoluble in water and acids. 

Examination of the Gastric Contents. — The micro- 
scopic examination of the contents of the stomach is much 
less important than the chemical. Fresh blood is easily 
recognized by the microscope. Disintegrated blood must 
be examined for chemically by the hemin test, as follows : 

Mix a little of the suspected material with a crystal or two 
of common salt, or place it on the thin layer of salt formed 




Fig. 105. — Crystals of cholesterin (after Striimpell). 

by slowly evaporating a small drop of normal salt solution 
on a slide. Cover with a cover-glass, and run in enough 
glacial acetic acid to fill up the space between slide and cover. 
Warm the slide over a flame for three-quarters to one 
minute until bubbles arise, adding more glacial acetic acid as 
evaporation takes place, until a faint reddish-brown tint 
appears. Then let the acetic acid evaporate entirely, and 
run glycerin in from the edge of the cover-glass. Micro- 
scopic examination will show dark -brown rhombic plates or 
columns of hemin if blood is present. 

Shreds of tissue or bits of mucous membrane are some- 
times found in the vomitus or removed by means of a 
stomach-tube. Examination of them in the fresh condition, 
or, more satisfactorily, in stained sections after hardening and 






HISTOLOGICAL METHODS. 38 1 

imbedding, will sometimes give definite information in regard 
to the condition of the mucous membrane, or render possible 
the diagnosis of a malignant growth. 

Examination for Free Hydrochloric Acid. — Of the fol- 
lowing tests, that with Congo-paper is the quickest and easiest, 
but shows only that a free acid is present. To prove that 
the free acid is hydrochloric acid the phloroglucin-vanillin 
test or one of the others is necessary. 

1. Congo-paper is turned blue by free acids only. Free 
hydrochloric acid turns it of a cornflower-blue, a tint obtained 
with lactic acid only when in much greater concentration 
than is ever present in the stomach. Congo-paper is used 
simply by dipping it into the stomach-contents, preferably 
after filtration. 

2. Gunzburg's Test with Phloroglucin-vanillin. — The solu- 
tion consists of — 

Phloroglucin, 2 ; 

Vanillin, I ; 

Absolute alcohol, 30. 

Three or four drops of this solution are placed with an equal 
amount of the filtrate from the stomach-contents in a porce- 
lain dish and carefully heated over a small flame. Keep the 
dish in constant motion, and do not allow the mixture to 
boil, because boiling prevents the reaction from taking place. 
If free hydrochloric acid is present, a rose-red mirror is pro- 
duced. The phloroglucin-vanillin solution does not always 
keep well, so that it is best to keep alcoholic solutions of 
phloroglucin and of vanillin in separate bottles, and to mix 
together one or two drops of each when required. 

3. Boas' Resorcin Test. — The solution consists of — 

Resublimed resorcin, 5 ; 

Cane-sugar, 3 ; 

Alcohol, 94 per cent., ad 100. 

It is used in the same manner as the phloroglucin-vanillin 
test. A similar but more transient mirror is produced. 

Topfer's Dimethyl-amido-azo-benzol test is highly recom- 



382 PATHOLOGICAL TECHNIQUE. 

mended by Simon as superior to the phloroglucin-vanillin 
test. "One or two drops of a 0.5 per cent, alcoholic solu- 
tion is added to a trace of the gastric contents, which need 
not be filtered ; in the presence of free HC1 a beautiful cherry- 
red color develops, which varies in intensity according to the 
amount of free HC1 present." 

Examination of the Feces. — In examining for tape- 
worms and their eggs it is often best to dilute the feces with 
water, and then to examine the sediment both macroscop- 
ically and under the microscope. (For ameba coli see p. 
292.) The other protozoa are best looked for in fresh slide 
preparations. 

For the cholera vibrio see p. 195 ; for the typhoid bacillus 
see p. 198. 

The membranous casts sometimes found in feces consist 
almost wholly of mucus, cylindrical epithelial cells, and 
leucocytes. Bits may be examined fresh, or the casts may 
be hardened and sections made and stained after imbedding 
in celloidin. 

Examination of the Urine. — Only those points are 
mentioned which come within the province of the patholo- 
gist. 

Of the animal parasites, the echinococcus and the filaria 
sanguinis hominis are the only important ones, and they are 
very rare (see pp. 294, 298). 

Of the vegetable parasites, tubercle bacilli and gonococci 
are the most common ; actinomycetes are very rare. 

New growths in the kidneys are accompanied with hemor- 
rhage in less than half of the cases, while new growths in 
the bladder almost invariably give rise to it. Fragments from 
new growths in the bladder are rare. A diagnosis of malig- 
nant disease from cells only is impossible. Pieces of tissue 
which show on microscopic examination the characteristic 
structure of cancer or other neoplasm must be obtained in 
order to render a diagnosis possible from the pathological 
(but not from the clinical) standpoint. 



HISTOLOGICAL METHODS. 383 

Partial List of Works Consulted. 

Friedlander : Mikroskopische Technik. 

Israel : Practicum der Pathologischen Histologic 

V. Jaksch : Klinische Diagnostik. Innerer Krankheiten. 

V. Kahlden : Technik der Histologischen Untersuchung. 

Lee : The Microtomisf s Vade-Mecum. 

Lenhartz : Mikroskopie und Chemie am Krankenbett. 

v. Lenhossek : Der Feinere Bau des Nervensy stems. 

Simon : Clinical Diagnosis. 

Thoma : Lehrbuch der Pathologischen Anatomie. 

Weigert : Beitrage zur Kenntniss der normalen menschlichen Neuroglia. 



INDEX 



Abbe's illuminating apparatus, 205 

camera lucida, 206 
Abbott's method of staining spores, 

100 
Abdominal cavity, 40 
fluid in, 29 
gas in, 29 
inspection of, 29 
opening of, 27 
Acetic acid, 217 
Acid, acetic, 217 
chromic, 218 
hydrochloric, 217 
nitric, 229 
osmic, 217, 261 

picric, as a decalcifying reagent, 

230 

as a stain, 272 

Acid-alcohol, 254 

Acid-fuchsin, 249 

Actinomyces, 176 

method of staining in sections, 
282 
Adhesions, pleural, 32 
Adrenals, 95 

removal of the, 46 
Agar-agar, glucose, 79 
glycerin, 80 
lactose-litmus, 80 
plain, 77 

slant culture of, 79 
stab culture of, 79 
Albuminous degeneration, 352 
Alcohol, 222 

Ranvier's one-third, 218 
Algeri, method of staining fatty 
degenerated nerve - fibers, 
326 
Alum-carmine, 244, 268 
25 



Alum-cochineal, 244, 268 
Alum-hematoxylin, aqueous, 241, 
267 
Delafield : s, 241, 267 
Ehrlich's, 242, 267 
stains, 266 
Ameba coli, 292 

differential stain for, 293 
Amputating knives, 18 
Amyloid, stains for, 362 

stain with Bismarck brown and 

gentian-violet, 364 
stain with iodin, 363 
stain with iodin-green, 364 
stain with methyl-violet, 364 
Anaerobic cultures, method of 
Buchner, 119 
method of Esmarch, 119 
method of Frankel, 121 
method of Liborius, 117, 118 
methods of preparation of, 117 
Aniline, 257 

Aniline and xylol, Weigert's mix- 
ture of, 258 
Aniline dyes, 245 

as nuclear stains, 269 
Aniline oil, 257 
Aniline water, 254 
Aniline-blue, Strobe's stain with, 

for nerve-fibers, 313 
Aniline-fuchsin, 247 
Animal parasites, 287 
Animals, care of, 117 
food of, 117 

inoculations of, 112-117, 181 
at autopsy, 96 
with the bacillus tuberculosis,. 

97 
with the pneumococcus, 97 

3S5 



3 86 



INDEX. 



Anterior incision, the long, 28 
Anthrax, bacillus of, 56 
Aorta, incision of the, 50 
Apparatus used in the examination 
of the blood, 327 
preparation of, 330 
Appendicitis, 181 

Autopsies, bacteriological examina- 
tions at, 89 
general rules in regard to, 21 
organs from, from which cultures 

are taken, 96 
private, 24 
Autopsy-knife, 18 
Autopsy-needle, 21 
Autopsy-record, 22 
Autopsy-table, 18 
Axillary glands, 29 
Axis-cylinders and their terminal 
processes, stains for, 312 

Babes' aniline-safranin, 248 
Bacillus aerogenes capsulatus, 173 
coli communis, 145, 181 
diphtherias, 137 
mallei, 164 

mucosus capsulatus, 168 
of anthrax, 156 
of glanders, 164 
of green pus, 160 
of influenza, 162 
of leprosy, 285 
of malignant edema, 175 
of syphilis, 286 
of tetanus, 171 
of typhoid fever, 141 

differential diagnosis of, 143 
serum or clump reaction 
with, 144 
of rhinoscleroma, 282 
proteus, 167 
pyocyaneus, 160 
tuberculosis, 92 

animal inoculations with, 97 
differentiation of, from smegma 
bacillus and bacillus of lep- 
rosy, 92 
Gabbet's stain for, 92 
lesions produced by, 97 



Bacteria, method of studying in 
cultures, 98 
not stained by Gram's method, 

92, 277 
stained by Gram's method, 92, 
280 
by tubercle bacillus method, 

. 283 
staining of, in tissues, 275 

Bacteriological apparatus, 70 
diagnosis, 121 
examinations, 70 
at autopsies, 89 
collection of material for, 178 
Balsam, Canada, 258 

xylol, 258 
Band-saw, 18 
Bergamot oil, 256 
Bethe's method of fixing methy- 
lene-blue stains of nerve- 
fibers, 315 
Bile-pigment, 365 
Bilirubin, 365 

Biondi-Heidenhain stain, 250, 272 
Birch-Hirschfeld's stain for amy- 
loid, 364 
Bismarck brown, 249 
Bladder, incision of the, 48 
Blood, apparatus used in the ex- 
amination of, 327 
cover-glass preparations of, 336 
elements of the, 338 
estimation of number of red cor- 
puscles of, 333 
examination of, 326 
hypostasis of, 26 
methods of staining, 342 
test for hemoglobin in, 332 
Blood-coloring matter, diffusion of, 

26 
Blood-serum, coagulation of, 82 
coagulator, 70 
collection of, 82 
method of preparing cultures on, 

94 
old method of preparation of, 

84 
preparation of, 81 
Boards, 21 



INDEX. 



337 



Boas' resorcin test for hydrochloric 

acid, 381 
Body, external examination of, 
26 
internal examination of, 27 
length of, 26 
restitution of, 67 

special inspection of the different 
parts of, 27 
Bodv-cavity, method of sewing up, 

68 
Boiling, 227 

Bone, methods of fixing and ex- 
amining, 348 
Schaffer's method of staining, 

349 
Bone-cutter, 21 
Bone-marrow, methods of fixing 

and examining, 346 
Bothriocephalus latus, 298 
Bottles, patent T. K., dropping-, 216 
Bouillon, preparation of, 75 
Brain, external examination of, 55 

Pitre's method of sectioning, 59 

removal of, 50, 53 

section of, 56 

Virchow's method of sectioning, 

. 58 
weight of, 55 

Breast, incision of, 29 

Buchner's method for anaerobic 

cultures, 119 
Bunge's method of staining fla- 

gella, 103 

Camera lucida, 206 

Canada balsam, 258 

Capsules and flagella, staining of, 

104 
Carbol-fuchsin, 247 
Carbol-gentian-violet, 248 
Carbolic acid and xylol mixture, 2 57 
Carbolic-acid water, 255 
Carbon, 366 
Corpora amylacea, reaction of, with 

iodin, 364 
Carmine, alum-, 244, 268 

lithium, 244, 269 

neutral, 245, 272 



Cartilage, methods of fixing and 

examining, 348 
Cartilage-knife, 19 
Caseation, 355 
Costotome, 21 
Catheter, 21 
Caustic potash, 218 
Cedar-wood, oil of, 257 
Celloidin, 231 

imbedding, 231 

microtome, 209 

sections, method of attaching to 
slides, 234 
Cellulose, reaction of, with iodin, 

364 
Central nervous system, methods 

of staining, 303 
Charcot-Leyden crystals, 379 
Chenzinsky-Plein stain for blood, 

344 
Chisel, 21 

Cholera, spirillum of, 152 
Cholesterin-crystals, 354. 

reaction of, with iodin, 364 
Chromic acid, 218 
Cleaning of slides and cover-slips, 

214 
Clearing reagents, 255 
Clinical bacteriology, 178 

pathology, 368 
Cloudy swelling, 352 
Cloves, oil of, 257 
Cochineal, alum-, 244 
Colloid, stains for, 358 
Colophonium, 258 
Combination stains, 252 
Comma bacillus, 152 
Congo-paper test for hydrochloric 

acid, 381 
Connective-tissue fibrillar, 300 

Ribbert's stain for, 301 

Unna's stain for, 301 

Van Gieson stain for, 300 
Contrast-stains, 271 
Cornet cover-glass forceps, 71 
Coronary arteries, opening of, 35 
Corrosive sublimate, 225 
Cover-glass preparations, 89, 180 

from cultures, 98 



3 88 



INDEX. 



Cover-glass preparations, import- 
ance of, 90 
mounting of, in water, 90 
of blood, 336 
staining of, 91 
Cover-slips, 214 
Cox's modification of Golgi's 

method, 312 
Cultivation of bacteria without 
oxygen, 117, 121 
method of Buchner, 119 
of Esmarch, 119 
of Frankel, 121 
of Liborius, 117, 118 
Culture-media, preparation of, 75 
agar-agar, plain, 77 
bouillon, 75 
blood-serum, 81 
gelatin, plain, 80 
glucose agar-agar, 79 
glucose bouillon, 76 
glucose, gelatin, 81 
glycerin agar-agar, 80 
lactose-litmus agar-agar, 80 
litmus milk, 85 

Lubinski's medium for the bacil- 
lus tuberculosis, 151 
peptone solution, Dunham, 86 
potato cultures, Bolton, 85 
serum agar-agar, 131 
sterilization of, 87 
urine-serum agar-agar, 132 
Cultures, cover-glass preparations 
from, 98 
examination of, 94 
from organs at autopsy, 96 
method of diluting, 95 
method of preparing on blood- 
serum, 94 
method of studying bacteria in, 98 
Curschmann's spirals, 377 
Cysts, echinococcus, 375 

ovarian and parovarian, 374 
pancreatic, 374 
renal, 375 

Damar, 258 

Darkschewitsch's method for serial 
sections, 238 



Delafield's alum-hematoxylin solu- 
tion, 241, 267 
Decalcification, 228 
Degenerations, albuminous, 352 
fatty, 352 

of the nervous system, 325 
Development of the skeleton, 26 
Diaphragm, position of, 30 
Diffuse stains, 249, 271 
Diffusion of blood-coloring matter, 

26 
Diluting cultures, method of, 95 
Dilutions, 108 
Dimethyl-amido-azo-benzol test for 

hydrochloric acid, 381 
Diphtheria, bacillus of, 137 
Diplococcus intracellularis menin- 
gitidis, 135 
pneumoniae. See Pneumococcus. 
Director, 21 
Discolorations, greenish, 26 

post-mortem, 26 
Dishes, oblong, rectangular, Petri, 
215 
staining, 214 
Steinach's sieve, 215 
Stender, 215 
Dittrich's plugs, 377 
Drop-bottle for microtome, 209 
Dropping-bottles, T. K. patent, 71 
Dunham's mixture of oils of cloves 
and thyme, 257 
peptone solution, 86 
Duodenum, incision of, 43 
Dura, inspection of, 53 
removal of, 53 

Ear, removal of middle, 63 
Echinococcus cysts, 375 
Ehrlich's acid-hematoxylin solu- 
tion, 242, 267 
aniline - gentian - violet solution, 

247 
hematoxylin-eosin stain for blood, 

343 
method of staining mastzellen, 
298 
tubercle bacilli, 284 
Elastic fibers, 301 



INDEX. 



389 



Elastic fibers, Herxheimer's method 
of staining, 303 
in sputum, 378 
phosphotungstic acid-hema- 

toxylin stain for, 302 
Unna's orcein stain for, 302 
Embolism of pulmonary artery, 35 
Enterotome, 20 
Eosin, 249, 271 

Eosin and methylene-blue, 270 
Erlicki's fluid, 228 
Erysipelas, 181 

Esmarch's method for anaerobic 
cultures, 119 
of roll cultures, no 
Esophagus, incision of, 40 
Exner's method of staining myelin- 

sheaths, 319 
Exudations, 370 
hemorrhagic, 370 
purulent, 371 
putrid, 371 
serous, 370 
Eye, examination of, 62 

Fatty degeneration, 352 
Feces, examination of, 382 
Fetus, measurements of, 66 

weight of, 66 
Fibrin, stains for, 355 

Weigert's stain for, 355 
Filaria sanguinis hominis, 294 
Filling of test-tubes, 86 
Filtering apparatus, bacterial, 72 
Fiocca's method of staining spores, 

100 
Fixing reagents, 220 
Flagella, staining of, 100-105 
Bunge's method, 103 
Loffler's method, 102 
Pitfield's method, 103 
Van Ermengem's method, 104 
Flemming's solution, 224 
Fluid in abdominal cavity, 29 
Fluids, examination of, 218, 370 
indifferent, 217 
macerating, 218 
Food for animals, 117 
Forceps, 21 



Forceps, Cornet cover-glass, 71 
Formaldehyde, 226 
Fractional sterilization, 88 
Fracture of the skull, 52 
Freezing microtome, 206 
Fresh material, examination of, 
216 
tissues, sections of, 216 

teased preparations of, 216 
Freud's gold stain for nerve-fibers, 

313 
Fuchsin, 247 
aniline-, 247 
carbol-, 247 

Gabbet's method of staining the 
bacillus tuberculosis, 92 
methylene-blue solution, 246 
Gall-bladder, dropsy of, 375 

removal of, 45 
Ganglion-cells, Lenhossek's method 
of staining, 308 
Nissl's method of staining, 307 
Gas in abdominal cavity, 29 

in pleural cavity, 31 
Gas stove, 71 
Gastric contents, examination of, 

380 
Gastro-intestinal tract, 41 

methods of fixing and exam- 
ining, 347 
Gelatin, glucose, preparation of, 8i 

plain, preparation of, 80 
General rules in regard to autopsies, 

21 
Generation of hydrogen, 120 
Gentian-violet, 247 
aniline-, 247 
carbol-, 248 
Stirling's, 248 
Gerlach's method of staining nerve- 
fibers, 313 
Giacomi's method of staining the 

bacillus of syphilis, 286 
Glanders, bacillus of, 164 

Loffler's method of staining in 

sections; 279 
Noniewicz's method of staining 
in sections, 280 



39° 



INDEX. 



Glanders, bacillus of, Schiitz's 
method of staining in sec- 
tions, 280 

Glands, axillary, 29 

Glucose agar-agar, preparation of, 

79 
bouillon, preparation of, 176 
gelatin, preparation of, 81 
Glycerin agar-agar, preparation of, 

80 
Glycerin-albumin mixture, Mayer's, 

255 
Glycogen, 361 
Gold, 260, 312 

Freud's stain for nerve-fibers 

with, 313 
Gerlach's stain for nerve-fibers 

with, 313 
Lowit's stain for nerve-fibers 

with, 261 
Ranvier's stain for nerve-fibers 
with, 261 
Golgi's method of staining the 

nervous system, 308 
Golgi stains, Cox's modification of, 
312 
Kallius' method of fixing, 311 
Gonococcus, 130, 278 

special culture-media for, 131 
Gout, 368 
Graduates, 21 
Gram's method of staining, 91-93, 

99, 277, 280, 281 
Gram-Weigert stain, 281 
Granulation-tissue, methods of fix- 
ing and examining, 345 
Giinzburg's test for hydrochloric 
acid, 381 

Hammer of soft iron, 21 

of steel, 21 
Hanging drop, method of exami- 
nation of, 112 

of preparation of, in, 112 
Harke's operation for exposing the 

naso-pharynx, 64 
Hatchet-chisel, 21 
Head, holder for, 21 
Heart, external inspection of, 32 



Heart, incisions of, 33 

measurements of, 36 

removal of, 33 

valves, water test of, 35 

weight of, 36 
Heidenhain-Biondi stain, 250 
Heidenhain's hematoxylin stain, 

268 
Heller's method of staining myelin- 

sheaths, 320 
Hemalum, acid, Mayer's, 242 

Mayer's, 242, 268 
Hematein, Mayer's glycerin-alum, 

242 
Hematoidin, 365 
Hematoxylin, aqueous, 241, 267 

Delafield's, 241, 267 

Ehrlich's acid, 242, 267 

Heidenhain's, 268 

phosphomolybdic acid, 243, 306 

phosphotungstic acid, 243, 325 

stains, 239 

Weigert's alcohol, 243 
Hemin test, 380 

Hemocytometer, Thoma-Zeiss, 327 
Hemoglobin, 365 

test for, in blood, 332 
Hemometer, Von Fleischl's, 329 
Hemosiderin, 365 
Hermann's solution, 225 
Herxheimer's method of staining 

elastic fibers, 303 
Histological methods, 204 
Holder for head, 21 
Hollow slide, 1 1 1 
Hoyer's method of staining mucin, 

357 
Hyalin, stains for, 358 
Hydrochloric acid, 217 

test for, in gastric contents, 

38i 
Hydrogen, bouillon cultures under, 
119, 120 
cultivation under, 119-121 
generation of, 120 
plate cultures under, 121 
Hydronephrosis, 375 
Hypodermic syringe, 71 
Hypostasis of blood, 26 



INDEX. 



39 



Illuminating apparatus, Abbe's, 

205 
Imbedding in celloidin, 231 
in paraffin, 234 
processes, 230 
Indifferent fluids, 217 
Influenza, bacillus of, 162 

method of staining in sections, 
279 
Injection of bacteria into mesen- 
teric vein, 114, 115 
Injection-masses, 219 
Injections, 218 

Inoculation of animals, 112-117 
at autopsies, 96 
of culture-tubes, 105, 106 
of guinea-pigs, 112, 113 
of mice, 11 5-1 17 
of rabbits, 11 3-1 15 
with the bacillus tuberculosis, 97 
with the pneumococcus, 97 
Instruments, autopsy, 18 

for histological purposes, 215 
Intestine, incision of, 43 

methods of fixing and examin- 
ing, 347 
Intraperitoneal inoculation, 113, 

116 
Intravenous inoculation, method 

of, 114 
Iodin, 253 

Lugol's solution of, 254 
tincture of, 253 
Iron, reactions for, 367 
Isolation of a bacterium in pure 
culture, method of, 107, 108 

Kaiserling's method of preserv- 
ing the natural colors of mu- 
seum preparations, 351 
Kallius' method of fixing Golgi's 

stains, 311 
Keratohyalin, Unna's stain for, 361 
Kidneys, 45 

examination of, 47 
measurements of, 47 
methods of fixing and examin- 
ing, 346 
removal of, 46 



Kidneys, weight of, 47 

Kipp's hydrogen generator, 120 

Knife, amputating, 18 

autopsy, 18 

cartilage, 19 

for freezing microtome, 208 

for microtomes, 212 

sharpening of microtome, 213 

Kuhne's method of staining the 

tubercle bacillus, 284 

methylene-blue solution, 246 

Laboratory outfit, 204 
Lactose-litmus agar-agar, 80 
Langhans' method for obtaining 
mounts of iodin stains of 
amyloid, 363 
! Larynx, incision of, 40 
Lavender, oil of, 257 
J Length of body, 26 
; Lenhossek's method of staining 

ganglion-cells, 308 
Leprosy, bacillus of, 285 
differentiation of, from bacillus 
tuberculosis, 93 
; Liborius, method of, 117, 118 
! Lithium carmine, 244, 269 
! Litmus-milk, preparation of, 85 
Liver, 44 

incision of, 44 
measurements of, 45 
methods of fixing and examin- 
ing, 347 
removal of, 44 
weight of, 45 
Loffler's blood-serum mixture, 81 
method of staining bacteria, 278 
method of staining flagella, 102 
method of staining the bacillus 
of glanders in sections, 279 
methylene-blue solution, 246, 
278 
Lowit's gold method, 261 
Lubinski's special culture-medium 
for the bacillus tuberculosis, 

151 
Luer's double rachiotome, 20 
Lumbar puncture, 371 
Lungs, incisions of, 38 



39 2 



INDEX. 



Lungs, methods of fixing and ex- 
amining, 346 
removal of, 37 

Lustgarten's method of staining 
the bacillus of syphilis, 286 

Macerating fluids, 218 
Malarial organisms, 218 

method of examining blood 
for, 290 
Malignant edema, bacillus of, 175 
Mallory's stain for actinomyces in 
sections, 282 
for amebae coli, 293 
for neuroglia-fibers, 322 

by means of phospho- 
tungstic-acid hematox- 
ylin, 325 
stain for elastic fibers, 302 
phosphomolybdic-acid hematox- 
ylin, 243 
phosphotungstic-acid hematox- 
ylin, 243 
Mamma, incision of, 29 
Marchi's fluid, 228 

method for staining fatty degen- 
erated nerves, 326 
Martinotti's picro-nigrosin, 250 
Mastzellen, 298 

Ehrlich's methods of staining, 

298 
Unna's methods of staining, 
299, 300 
Mayer's acid hemalum, 242 
glycerin-albumin mixture, 255 
glycerin-alum-hematein solution, 

242 
hemalum, 242, 268 
muchematein, 243 
Mechanical stage, 206 
Mediastinum, anterior, 32 
Melanin, 365 
Mesenteric veins, inoculation into, 

114, 115 
Mesentery, removal of, 43 
Metallic stains or impregnations, 

258 
Methemoglobin, 365 
Method of diluting cultures, 95 



Method of distributing material 
over surface of culture 
medium, 95 

of fixing and examining special 
organs and tissues, 344 

of preparing cultures on blood- 
serum, 94 

of sterilizing surface of organs, 

95 
Methods, histological, 204 

of studying bacteria in cultures, 
98 
Methylene-blue, 246 
eosin and, 270 
Gabbet's solution of, 246 
Kiihne's solution of, 246 
Loffler's solution of, 246 

method of staining bacteria 
with, 278 
Sahli's solution of, 247 
stain for nerve-fibers, 314 
Unna's alkaline solution of, 246, 
270 
polychrome solution of, 247 
Methyl-violet, 248 
Micrococcus lanceolatus. See 
Pnewnococcus. 
pneumonias crouposse. See 

Pnewnococcus. 
of sputum septicemia. See 
Pneumococcus. 
Micrococcus tetragenus, 133 
Microscopes, 204 
Microtome, celloidin, 209 
freezing, 206 
knives, 212 

knives, sharpening of, 213 
paraffin, 210 
Mitosis, 273 
Moller's method of staining spores, 

100 
Motility of bacteria, 1 1 1 

method of determining, m 
Mounting reagents, 258 
Mouse-holder, 116 
Muchematein, Mayer's, 243 
Mucin, Hoyer's method of staining, 

357 
stains for, 356 



INDEX. 



393 



Mucin, Unna's method of staining, 

358 
Miiller's fluid, 227 
Museum preparations, 350 

Kaiserling's method of pre- 
serving the natural colors 

of, 351 
Myelin-sheaths, Exner's method 

of staining, 319 
Heller's method of staining, 320 
Marchi and Algeri's method of 

staining fatty degenerated, 

326 
Pal's modification of Weigert's 

stain for, 318 
Robertson's method of stain- 
ing, 320 
stains for, 316 
Weigert's quick method of 

mordanting, 316 
Weigert's stain for, 317 
Myelotome, 18 

Nasopharynx, examination of, 
by Harke's operation, 64 

Neck, organs of, 39 

Necrosis, 354 

Nerve-fibers, Bethe's method of fix- 
ing methylene-blue, stains 

of, 315 
chlorid of iron and dinitro-resor- 

cin method, 314 
degenerations of, 325 
gold stains for, 312 
Marchi and Algeri's method of 

staining fatty degenerated, 

326 
methylene-blue stain for, 314 
Strobe's aniline-blue stain for, 

313 
Nervous system, general stains for, 

305 
Golgi's method of staining, 

308 
methods of staining, 303 
stains for the ganglion-cells, 

307 
stains for the myelin-sheaths, 

3i6 



Nervous system, stains for the neu- 
roglia-fibers, 321 

Neuroglia-fibers, Mallory's stains 
for, 322 
Weigert's stain for, 323 

Neutral carmine, 245, 272 

New-born child, examination of, 65 
weight of organs of, 67 

Nigrosin, as a stain for the nervous 
system, 307 
picro-, 250 

Nissl's method of staining gan- 
glion-cells, 307 

Nitric acid, 229 

Noniewicz's method of staining the 
bacillus of glanders in sec- 
tions, 280 

Nuclear stains, 265 

Nutrition, general, 26 

Oil of bergamot, 256 

of cedar-wood, 257 

of cloves, 257 

of lavender, 257 

of origanum, 256 

of thyme, 257 
Oil-immersion lens, 205 
Oleum origani cretici, 256 
Omentum, removal of, 42 
Orcein, 253 
Organs from which cultures are 

taken at autopsies, 96 
Origanum oil, 256 
Orth's discharging fluid, 254 

fluid, 224 

lithium carmine, 244 
Osmic acid, 217, 261 

stain for myelin-sheaths, 319 
Ovarian cysts, 374 
Ovaries, incision of, 48 

weight of, 48 

Pacchionian granulations, 53 
Pal's modification of Weigert's 

myelin-sheath stain, 318 
Pancreas, incision of, 44 

removal of, 43 

weight of, 44 
Pancreatic cyst or fistula, 374 



394 



INDEX. 



Paraffin, 210 
bath, 210 
imbedding, 234 
microtome, 210 

sections, method of attaching to 
the slide, 236 
Parhemoglobin, 365 
Parovarian cysts, 374 
Pathological products, 352 
Pelvic organs, removal of, 47 
Penis, incision of, 48 

removal of, 49 
Pepton solution, preparation of, 86 
Pericardium, opening of, 32 
Peritonitis, 181 

Perosmic acid. See Osmic Acid. 
Petri dish, 108 

oblong rectangular, 2 r 5 
Petrifaction, 368 

Phloroglucin and nitric acid, 229 
-vanillin test for hydrochloric 
acid, 381 
Phosphomolybdic-acid hematoxy- 
lin, 243, 306 
Phosphotungstic-acid hematoxylin, 

243, 302, 306 
Pia, removal of, 56 
Pianese's fixing solution, 225 

staining solutions, 250 
Picric acid, 230, 249, 272 
Picro-nigrosin, 250 
Pigmentation, 365 
Pigments, autochthonous, 365 
extraneous, 365 
hematogenous, 365 
Pitfleld's method of staining flagella, 

103 
Pitre's method of sectioning the 

brain, 59 
Plasma cells, Unna's stains for, 

300 
Plate cultures, 108 
Plate method of Petri, 108 
Platinum needle for handling sec- 
tions, 216 
Platinum wire, 72 
Platinum-wire loop, 72 
Pleural cavity, adhesions in, 32 
gas in, 31 



Pleural cavity, inspection of, 31 

Pneumococcus, 128-130 
animal inoculations with, 97 
Curry's stain for capsule of, 93 
Gram stain for capsule of, 94 
Welch's stain for capsule of, 93 

Poikilocytosis, 339 

Portal vein, incision of, 41 

Post-mortem discolorations, 26 
examinations, 17 
rigidity, 26 

Potato cultures, preparation of, 85 

Private autopsies, 24 

Probes, 21 

Protozoa, 287 

Pseudo-mucin, 358 

Pulmonary artery, embolism of, 35 

Pure cultures, method of obtaining, 
105 

Quantity of bacteria for inocula- 
tion, 116, 117 

Rabl's chromoformic-acid solu- 
tion, 225 

Rachiotome, Luer's, 20 

Ranvier's gold method, 261 
one-third alcohol, 218 

Record of autopsies, 22 

Rectum, incision of, 48 

Renal cysts, 375 

Resorcin test for hydrochloric acid, 
381 

Restitution of the body, 67 

Rhinoscleroma, bacillus of, 282 

Ribbert, method of staining con- 
nective-tissue fibrillar, 301 

Rigidity, post-mortem, 26 

Robertson's method of staining 
myelin-sheaths, 320 

Roll cultures, no 

Round-worms, 294 

Rubber gloves, 23 

Running water, 213 

Sahli's borax methylene-blue solu- 
tion, 247 
Safranin, 248 

Babes' aniline, 248 



INDEX. 



395 



Saw, 20 

Scales, 18 

Scalpel, 19 

Schiitz's method of staining the 

bacillus of glanders, 280 
Schaffer's safranin stain for bone, 

349 
Schallibaum's solution, 255 
Scissors, 19 
Semilunar ganglia, 49 
Serial sections by celloidin method, 

237 
by paraffin method, 239 
Serum agar-agar, 13 J 
Serum reaction with the bacillus of 

typhoid fever, 144 
Sharpening of microtome knives, 

213 
Sieve-dish, Steinach's, 215 
Silver, nitrate of, 258 
Skeleton, development of, 26 
Skin, general condition of, 26 
methods of fixing and examin- 
ing, 349 
Skull, fracture of, 52 
incision of, 51 
of infant, opening of, 52 
Slee's method of fastening the cal- 

varia, 68 
Slides, 213 

cleaning of, 214 
Smegma bacillus, 286 

differentiation of, from the 
bacillus tuberculosis, 92 
Spatula, 215 

Spinal cord, method of incising, 
62 
removal of, 60 
Spine, removal of, 50 
Spirillum of Asiatic cholera, 152 
Spleen, incision of, 41 
measurements of, 41 
methods of fixing and examin- 
ing, 346 
removal of, 41 
weight of, 41 
Sponges, 21 

Spore-formation, study of, 112 
Spores, staining of, 100 



Spores, Abbott's method of stain- 
ing, 100 
Fiocca's method of staining, 100 
Moller's method of staining, 

100 
sterilization of, 89 
Sporozoa, 294 

Sputum, examination of, 376 
for tubercle bacilli, 186 
Staining in mass, 273 
methods for sections, 262 

for cover-glass preparations, 

9i 

solutions, 239 
Staining-dishes, 214 
Starch-granules, reaction of, with 

iodin, 364 
Staphylococcus cereus albus, 124 

cereus flavus, 124 

epidermidis albus, 124 

pyogenes albus, 124 

pyogenes aureus, 121, 181 

pyogenes citreus, 124 
Steinach's sieve-dish, 215 
Stender dishes, 215 
Sterilization, fractional, 88 

of culture-media, 87 

of gelatin tubes, 81 

of organs, 95 

time required for, 88 
Sterilizer, hot-air, 70 

steam, 70 
Stieda's stain for iron and nuclei, 

367 

Stirling's solution of gentian-violet, 
248 

Stomach, incision of, 43 

methods of fixing and examin- 
ing, 347 
removal .of, 43 

Strobe's aniline-blue stain for 
nerve-fibers, 313 

Streptococcus pyogenes, 124, 181 

Subcutaneous inoculations, 112, 

113. ii5 
of guinea-pigs, 112 
of mice, 1 15 
of rabbits, 113 
Suggestions to beginners, 23 



396 



INDEX. 



Suppurative processes, 181 
Suprarenal capsule. See Adrenal. 
Syphilis, bacillus of, 286 
Syracuse solid watch-glasses, 215 
Swab, 179 

TAENIA ECHINOCOCCUS, 298 

mediocanellata s. saginata, 298 
solium, 296 
Tape-worms, 296 

bothriocephalus latus, 298 
taenia echinococcus, 298 
taenia mediocanellata, 298 
taenia solium, 296 
Teased preparations of fresh tis- 
sues, 216 
Test-tubes, 71 
filling of, 86 
new, 74 
old, 74 

preparation of, 74 
Testes, incision of, 48 

weight of, 48 
Tetanus, bacillus of, 171 
Thermo-regulator, 73 
Thoma-Zeiss hemocytometer, 327 
Thoracic duct, 49 
Thorax, opening of, 30 
Thyme, oil of, 257 
Thymus gland, 32 
Thyroid gland, incision of, 40 
Tin cups, 73 
Tonsils, incision of, 40 
Topfer's dimethyl-amido-azo-ben- 
zol test for hydrochloric acid, 
38i 
Touton's method of staining gono- 

cocci in sections, 278 
Trachea, incision of, 40 
Transudations, 370 
Trichinae, 295 
Trichloracetic acid, 230 
Tuberculosis, bacillus of, 148 

diagnosis of, from animal in- 
oculations, 97 
Ehrlich's method of staining, 

284 
Kiihne's method of staining, 
286 



Tuberculosis, bacillus of, method 
of staining in celloidin sec- 
tions, 285 
Ziehl-Neelsen-Gabbet method 
of staining, 284 
Twine, 21 
Typhoid fever, bacillus of, 141 

method of staining in sec- 
tions, 278 

Unna's alkaline methylene-blue 
solution, 246, 270 
orcein stain for elastic fibers, 302 
polychrome methylene-blue solu- 
tion, 247 
stain for connective-tissue fibril- 

lae, 301 
stain for hyalin and colloid, 360 
stain for kerato-hyalin, 361 
stain for mastzellen, 299, 300 
stain for mucin, 358 
Urine, examination of, 382 
Urine-serum agar-agar, 132, 133 
Uric-acid salts in gout, 368 
Uterine scrapings, examination of, 

369 
Uterus, incision of, 48 

Vagina, incision of, 48 

Valves of heart, water test for, 35 

Van Ermengem's method of stain- 
ing flagella, 104 

Van Gieson's stain, 249, 272 

stain for central nervous sys- 
tem, 306 
stain for connective-tissue fibril- 
lae, 300 

Von Fleischl's hemometer, 329 

Vena cava, incision of, 49 

Virchow's method of sectioning the 
brain, 58 

Vulcanized fiber, 211 

Watch-glasses, Syracuse solid, 

215 
Water, running, 213 

test of valves of heart, 35 
Weigert's alcohol hematoxylin, 

243 



INDEX. 



397 



Weigert's differential stain for neu- 

roglia-fibers, 323 
method for serial sections, 238 
mixture of aniline and xylol, 258 
mixture of carbolic acid and 

xylol, 257 
modification of Gram's stain, 281 
quick method of mordanting 

myelin-sheaths, 316 
stain for fibrin, 355 
stain for myelin-sheaths, 317 
Welch's method of staining: the 



capsule of the pneumococ- 
cus, 93 
Wire baskets, 72 

Xylol, 257 
Xylol balsam, 258 

Zenker's fluid, 223 

Ziehl-Neelsen-Gabbet method of 
staining the bacillus tuber- 
culosis, 284 

Ziehl-Neelsen's carbol-fuchsin, 247 






©i 

i 



I 



2 




PUBLISHED BY 



W. g. gaandep^ ^25 Walnut gtpeet, 
epyiadelpl^ia. 



MR. SAUNDERS, in presenting to the profession the fol- 
lowing list of publications, begs to state that the aim 
has been to make them worthy of the confidence of 
medical book-buyers by the high standard of authorship 
and by the excellence of typography, paper, printing, 
and binding. 

The works indicated in the Index (see next page) with 
an asterisk (*) are sold by subscription (not by booksellers), 
usually through travelling solicitors, but they can be ob- 
tained direct from the office of publication (charges of ship- 
ment prepaid) by remitting the quoted prices. Full descrip- 
tive circulars of such works will be sent to any address upon 
application. 

All the other books advertised in this catalogue are 
commonly for sale by booksellers in all parts of the United 
States; but any book will be sent by the publisher to any 
address (post-paid) on receipt of the price herein given. 



CONTENTS 



Anatomy. page 

Haynes, Manual of Anatomy 24 

Nancrede, Anatomy and Manual of Dissection . 16 
Nancrede, Essentials of Anatomy 26 

Bacteriology. 

Ball, Essentials of Bacteriology 26 

Crookshank, A Text-Book of Bacteriology . . , 13 

-Frothingham, Laboratory Guide 20 

JticFarland, Text-Book of Pathogenic Bacteria . 15 

Botany. 

Bastin, Laboratory Exercises in Botany 20 

Chemistry and Physics. 

Brockway, Essentials of Physics 26 

Wolff, Essentials of Chemistry 26 

Children. 

*An American Text-Book of Diseases of Children 8 

Griffith, Care of the Baby 21 

Powell, Essentials of Diseases of Children ... 26 

Clinical Charts, B-iet, and Biet Lists. 

Hart, Diet in Sickness and in Health 22 

Keen, Operation Blank 19 

Laine, Temperature Chart 16 

Meigs, Feeding in Early Infancy 14 

Starr, Diets for Infants and Children 22 

Thomas, Detachable Diet Lists, etc 22 

Biag-nosis. 

Cohen and Eshner, Essentials of Diagnosis ... 26 

MacDonald, Surgical Diagnosis and Treatment . 29 

Vierordt and Stuart. Medical Diagnosis .... 10 
Corwin, Essentials of the Physical Diagnosis of 

the Thorax 18 

Bictionaries, 

Keating and Hamilton, New Pronouncing Dic- 
tionary of Medicine . . 10 

Morten, Nurses' Dictionary of Medical Terms . 22 
Saunders' Pocket Medical Lexicon 17 

Ear. 

Gleason, Essentials of Diseases of the Ear ... 26 

Electricity. 
Stewart and Lawrance, Essentials of Medical 
Electricity 26 

Embryology. 

Heisler, Text-Book of Embryology 29 

Eye, Jfose, and Throat. 

De Schweinitz, Diseases of the Eye 14 

Jackson and Gleason, Essentials of Diseases of 

Eye, Nose, and Throat 26 

Kyle, Manual of Diseases of Nose and Throat . . 24 

Crenito-nrinary. 

Hyde, Syphilis and the Venereal Diseases ... 24 
Martin, Essentials of Minor Surgery, Bandaging, 

and Venereal Diseases 26 

Saundby, Renal and Urinary Diseases 27 

Gynecology. 

*An American Text-Book of Gynecology .... 9 

Cragin, Essentials of Gynecology 26 

Garrigues, Diseases of Women 18 

Long, Syllabus of Gynecology 19 

Histology. 

Clarkson, Text-Book of Histology 15 

Eife Insurance. 

Keating, How to Examine for Life Insurance . . 21 
Materia Medica and Therapeutics. 

*An American Text Book of Applied Therapeu- 
tics 4 

Butler, Text-Book of Materia Medica, Therapeu- 
tics, and Pharmacology 27 

Cerna, Notes on the Newer Remedies 17 

Griffin, Manual of Materia Medica and Therapeu- 
tics 24 

Morris. Essentials of Materia Medica, etc. ... 26 
2 



PAGE 

Saunders' Pocket Medical Formulary 17 

Stevens, Manual of Therapeutics ] 17 

Thornton, Dose-Book and Prescription- Writing". 24 

Warren, Surgical Pathology and Therapeutics . 11 

Medical Jurisprudence. 

Chapman, Medical Jurisprudence and Toxi- 
cology 24 

Semple, Essentials of Legal Medicine, etc. ... 26 

Medicine. 

*An American Text-Book of Practice 7 

*Gould and Pyle, Anomalies and Curiosities of 

Medicine 28 

Lockwood, Manual of the Practice of Medicine 24 
Morris, Essentials of the Practice of Medicine . 26 
Saunders' American Year-Book of Medicine and 

Surgery 30 

Stevens, Manual of the Practice of Medicine . . 16 

Xervous Biseases and Insanity. 

Burr, Manual of Nervous Diseases 24 

Shaw,Essentials of Nervous Diseases and Insanity 26 

Nursing. 

Griffith, Care of the Baby 21 

Hampton, Nursing: its Principles and Practice 21 

Stoney, Practical Points in Private Nursing ... 13 

Obstetrics. 

*An American Text-Book of Obstetrics 5 

Ashton, Essentials of Obstetrics 26 

Boisliniere, Obstetric Accidents 20 

Dorland, Manual of Obstetrics 24 

Morris, Syllabus of Obstetrical Lectures 19 

Pathology. 

Semple, Essentials of Pathology and Morbid 

Anatomy 26 

Senn, Pathology and Surgical Treatment of 

Tumors n 

Stengel, Manual of Pathology V. 24 

Warren, Surgical Pathology'and Therapeutics . 11 

Pharmacy. 

Sayre, Essentials of Pharmacy 26 

Physiology. 

*An American Text-Book of Physiology .... 3 

Hare, Essentials of Physiology 26 

Raymond, Manual of Physiology 24 

Stewart, A Manual of Physiology 15 

Skiagraphy. 

Rowland, Archives of Clinical Skiagraphy ... 16 

Skin. 

*Pictorial Atlas of Skin Diseases 12 

Stelwagon, Essentials of Diseases of the Skin . . 26 

Surgery. 

*An American Text-Book of Surgery 6 

Beck, Surgical Asepsis 24 

DaCosta, Manual of Surgery 24 

Keen, Operation Blank 19 

MacDonald, Surgical Diagnosis and Treatment . 29 

Martin, Essentials of Surgery 26 

Martin, Essentials of Minor Surgery, etc 26 

Pye, Elementary Bandaging and Surgical Dress- 
ing 27 

Saunders' American Year-Book of Medicine and 

Surgery 30 

Senn, Pathology and Surgical Treatment of 

Tumors 11 

Senn, Syllabus of Surgery 19 

Warren, Surgical Pathology and Therapeutics . 11 

Urine. 

Wolff, Essentials of Examination of Urine ... 26 

Miscellaneous. 

Gross, Autobiography of 12 

Saunders' New Aid Series of Manuals .... 23, 24 

Saunders' Question Compends 25, 26 

Thresh, Water and Water Supplies 15 



CATALOGUE OF MEDICAL WORKS. 



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AN AMERICAN TEXT-BOOK OF PHYSIOLOGY. Edited by 
William H. Howell, Ph. D., M. D., Professor of Physiology in the Johns 
Hopkins University, Baltimore, Md. One handsome octavo volume of 1052 
pages, fully illustrated. Prices: Cloth, $6.00 net; Sheep or Half-Morocco, 
$7.00 net. 

This work is the most notable attempt yet made in America to combine in one 
volume the entire subject of Human Physiology by well-known teachers who have 
given especial study to that part of the subject upon which they write. The 
completed work represents the present status of the science of Physiology, par- 
ticularly from the standpoint of the student of medicine and of the medical 
practitioner. 

American teachers of physiology have not been altogether satisfied with the 
text-books at their disposal. The defects of most of the older books are that they 
have not kept pace with the rapid changes in modern physiology, while few if any 
of the newer books have been uniformly satisfactory in their treatment of all parts 
of this many-sided science. Indeed, the literature of experimental physiology is 
so great that it would seem to be almost impossible for any one teacher to keep 
thoroughly informed on all topics. 

The collaboration of several teachers in the preparation of an elementary text- 
book of physiology is unusual, the almost invariable rule heretofore having been 
for a single author to write the entire book. One of the advantages to be derived 
from this collaboration method is that the more limited literature necessary for 
consultation by each author has enabled him to base his elementary account upon 
a comprehensive -knowledge of the subject assigned to him; another, and perhaps 
the most important, advantage, is that the student gains the point of view of a 
number of teachers. In a measure he reaps the same benefit as would be obtained 
by following courses of instruction under different teachers. The different stand- 
points assumed, and the differences in emphasis laid upon the various lines of pro- 
cedure, chemical, physical, and anatomical, should give the student a better insight 
into the methods of the science as it exists to-day. The work will also be found 
useful to many medical practitioners who may wish to keep in touch with the 
development of modern physiology. 

The main divisions of the subject-matter are as follows : General Physiology of 
Muscle and Nerve — Secretion — Chemistry of Digestion and Nutrition — Movements 
of the Alimentary Canal, Bladder, and Ureter — Blood and Lymph — Circulation — 
Respiration — Animal Heat — Central Nervous System — Special Senses — Special 
Muscular Mechanisms — Reproduction — Chemistry of the Animal Body. 

CONTRIBUTORS: 



HENRY P. BOWDITCH, M. D„ 

Professor of Physiology, Harvard Medical School. 

JOHN G. CURTIS, M. D., 

Professor of Physiology, Columbia University, N. Y. 
(College of Physicians and Surgeons). 

HENRY H. DONALDSON, Ph. D., 

Head-Professor of Neurology, University of Chicago. 



WARREN P. LOMBARD, M. D., 

Professor of Physiology, University of Michigan. 

GRAHAM LUSK, Ph.D., 

Professor of Physiology, Yale Medical School. 

W. T. PORTER, M. D., 

Assistant Professor of Physiology, Harvard Medical 
School. 



W. H. HOWELL, Ph. D., M. D., j EDWARD T. REICHERT, ML D., 

Professor of Physiology, Johns Hopkins University. | Professor of Physiology, University of Pennsylvania. 



FREDERIC S. LEE, Ph.D., 

Adjunct Prof of Physiology, Columbia University, 
N. Y. (College of Physicians and Surgeons). 



HENRY SEWALL. Ph. D., M. D., 

Professor of Physiology, Medical Department, Uni- 
versity of Denver. 



W. B. SAUNDERS' ILLUSTRATED 



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AN AMERICAN TEXT-BOOK OF APPLIED THERAPEU- 
TICS. For the Use of Practitioners and Students. Edited by 
James C. Wilson, M. D., Professor of the Practice of Medicine and of 
Clinical Medicine in the Jefferson Medical College. One handsome octavo 
volume of 1326 pages. Illustrated. Prices: Cloth, $7.00 net; Sheep or 
Half-Morocco, $8.00 net. 

The arrangement of this volume has been based, so far as possible, upon mod- 
ern pathologic doctrines, beginning with the intoxications and following with 
infections, diseases due to internal parasites, diseases of undetermined origin, and 
finally the disorders of the several bodily systems — digestive, respiratory, circu- 
latory, renal, nervous, and cutaneous. It was thought proper to include also a 
consideration of the disorders of pregnancy. 

The list of contributors comprises the names of many who have acquired dis- 
tinction as practitioners and teachers of practice, of clinical medicine, and of the 
specialties. 

CONTRIBUTORS: 



Dr. I. E. Atkinson, Baltimore, Md. 
Sanger Brown, Chicago, 111. 
John B. Chapin, Philadelphia, Pa. 
William C. Dabney, Charlottesville, Va. 
John Chalmers DaCosta, Phila., Pa. 
I. N. Danforth, Chicago, 111. 
John L. Dawson, Jr., Charleston, S. C. 
F. X. Dercum, Philadelphia, Pa. 
George Dock, Ann Arbor, Mich. 
Robert T. Edes, Jamaica Plain, Mass. 
Augustus A. Eshner, Philadelphia, Pa. 
J. T. Eskridge, Denver, Col. 
F. Forchheimer, Cincinnati, O. 
Carl Frese, Philadelphia, Pa. 
Edwin E. Graham, Philadelphia, Pa. 
John Guiteras, Philadelphia, Pa. 
Frederick P. Henry, Philadelphia, Pa. 
Guy Hinsdale, Philadelphia, Pa. 
Orville Horwitz, Philadelphia, Pa. 
W. W. Johnston, Washington, D. C. 
Ernest Laplace, Philadelphia, Pa. 
A. Laveran, Paris, France. 



Dr. James Hendrie Lloyd, Phila., Pa. 
John Noland Mackenzie, Bait., Md. 
J. W. McLaughlin, Austin, Texas. 
A. Lawrence Mason, Boston, Mass. 
Charles K. Mills, Philadelphia, Pa. 
John K. Mitchell, Philadelphia, Pa. 
W. P. Northrup, New York City. 
William Osier, Baltimore, Md. 
Frederick A. Packard, Phila., Pa. 
Theophilus Parvin, Philadelphia, Pa. 
Beaven Rake, London, England. 
E. O. Shakespeare, Philadelphia, Pa. 
Wharton Sinkler, Philadelphia, Pa. 
Louis Starr, Philadelphia, Pa. 
Henry W. Stelwagon, Phila., Pa. 
James Stewart, Montreal, Canada. 
Charles G. Stockton, Buffalo, N. Y. 
James Tyson, Philadelphia, Pa. 
Victor C. Vaughan, Ann Arbor, Mich. 
James T. Whittaker, Cincinnati, O. 
J. C. Wilson, Philadelphia, Pa. 



The articles, with two exceptions, are the contributions of American writers. 
Written from the standpoint of the practitioner, the aim of the work is to facili- 
tate the application of knowledge to the prevention, the cure, and the alleviation 
of disease. The endeavor throughout has been to conform to the title of the 
book — Applied Therapeutics — to indicate the course of treatment to be pursued 
at the bedside, rather than to name a list of drugs that have been used at one 
time or another. 

While the scientific superiority and the practical desirability of the metric 
system of weights and measures is admitted, it has not been deemed best to 
discard entirely the older system of figures, so that both sets have been given 
where occasion demanded. 



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AN AMERICAN TEXT-BOOK OF OBSTETRICS. Edited by Rich- 
ard C. Norris, M. D.; Art Editor, Robert L. Dickinson, M. D. One 
handsome octavo volume of over iooo pages, with nearly 900 colored and 
half-tone illustrations. Prices: Cloth, $7.00; Sheep or Half-Morocco, $8.00. 

The advent of each successive volume of the series of the American Text- 
Books has been signalized by the most flattering comment from both the Press and 
the Profession. The high consideration received by these text-books, and their 
attainment to an authoritative position in current medical literature, have been 
matters of deep international interest, which finds its fullest expression in the 
demand for these publications from all parts of the civilized world. 

In the preparation of the "American Text-Book of Obstetrics " the editor 
has called to his aid proficient collaborators whose professional prominence entitles 
them to recognition, and whose disquisitions exemplify Practical Obstetrics. 
While these writers were each assigned special themes for discussion, the correla- 
tion of the subject-matter is, nevertheless, such as ensures logical connection in 
treatment, the deductions of which thoroughly represent the latest advances in the 
science, and which elucidate the best modern methods of procedure. 

The more conspicuous feature of the treatise is its wealth of illustrative matter. 
The production of the illustrations had been in progress for several years, under 
the personal supervision of Robert L. Dickinson, M. D., to whose artistic judg- 
ment and professional experience is due the most sumptuously illustrated 
•work of the period. By means of the photographic art, combined with the 
skill of the artist and draughtsman, conventional illustration is superseded by 
rational methods of delineation. 

Furthermore, the volume is a revelation as to the possibilities that may be 
reached in mechanical execution, through the unsparing hand of its publisher. 



CONTRIBUTORS 



Dr. James C. Cameron. 
Edward P. Davis. 
Robert L. Dickinson. 
Charles Warrington Earle. 
James H. Etheridge. 
Barton Cooke Hirst. 
Henry J. Garrigues. 
Charles Jevvett. 



Dr. Howard A. Kelly. 
Richard C. Norris. 
Chauncey D. Palmer. 
Theophilus Parvin. 
George A. Piersol. 
Edward Reynolds. 
Henry Schwarz. 



" At first glance we are overwhelmed by the magnitude of this work in several respects, viz. : 
First, by the size of the volume, then by the array of eminent teachers in this department who have 
taken part in its production, then by the profuseness and character of the illustrations, and last, but 
not least, the conciseness and clearness with which the text is rendered. This is an entirely new 
composition, embodying the highest knowledge of the art as it stands to-day by authors who occupy 
the front rank in their specialty, and there are many of them. We cannot turn over these pages 
without being struck by the superb illustrations which adorn so many of them. We are confident 
that this most practical work will find instant appreciation by practitioners as well as students." — 
New York Medical Times. 



Permit me to say that your American Text-Book of Obstetrics is the most magnificent medical 
work that I have ever seen. I congratulate you and thank you for this superb work, which alone is 
sufficient to place you first in the ranks of medical publishers. 

With profound respect I am sincerely yours, 

Alex. J. C. Skene. 



W. B. SAUNDERS ILLUSTRATED 



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AN AMERICAN TEXT-BOOK OF SURGERY. Edited by Wil- 
liam W. Keen, M. D., LL.D., and J. William White, M. D., Ph. D. 
Forming one handsome royal-octavo volume of 1250 pages (10x7 inches), 
with 500 wood-cuts in text, and 37 colored and half-tone plates, many of 
them engraved from original photographs and drawings furnished by the 
authors. Prices : Cloth, $7.00 ; Sheep or Half-Morocco, $8.00 net. 

SECOND EDITION, REVISED AND ENLARGED, 

With a Section devoted to " The Use of the Rbntgen Rays in Surgery." 

The want of a text-book which could be used by the practitioner and at the 
same time be recommended to the medical student has been deeply felt, especially 
by teachers of surgery ; hence, when it was sug- 
gested to a number of these that it would be 
well to unite in preparing a text-book of this 
description, great unanimity of opinion was 
found to exist, and the gentlemen below named 
gladly consented to join in its production. 

Especial prominence has been given to Surg- 
ical Bacteriology, a feature which is believed to 
be unique in a surgical text-book in the English 
language. Asepsis and Antisepsis have received 
particular attention. The text is brought well 
up to date in such important branches as cere- 
bral, spinal, intestinal, and pelvic surgery, the 
most important and newest operations in these 
departments being described and illustrated. 

The text of the entire book has been sub- 
mitted to all the authors for their mutual criti- 
cism and revision — an idea in book-making 
that is entirely new and original. The book as 
a whole, therefore, expresses on all the im- 
portant surgical topics of the day the consensus 
of opinion of the eminent surgeons who have joined in its preparation. 

One of the most attractive features of the book is its illustrations. Very many 
of them are original and faithful reproductions of photographs taken directly from 
.patients or from specimens, and the modern improvements in the art of engraving 
have enabled the publisher to produce illustrations which it is believed are superior 
to those in any similar work. 

CONTRIBUTORS: 




Specimen Illustration [largely reduced}. 



Dr. Charles H. Burnett, Philadelphia. 
Phineas S. Conner, Cincinnati. 
Frederic S. Dennis, New York. 
William W. Keen, Philadelphia. 
Charles B. Nancrede, Ann Arbor, Mich. 
Roswell Park, Buffalo, N. Y. 
Lewis S. Pilcher, Brooklyn, N. Y. 



Dr. Nicholas Senn, Chicago. 

Francis J. Shepherd, Montreal, Canada. 

Lewis A. Stimson, New York. 

William Thomson, Philadelphia. 

J. Collins Warren, Boston. 

J. William White, Philadelphia. 



" If this text-book is a fair reflex of the present position of American surgery, we must admit 
it is of a very high order of merit, and that English surgeons will have to look very carefully to 
their laurels if they are to preserve a position in the van of surgical practice." — London Lancet. 

" The soundness of the teachings contained in this work needs no stronger guarantee than is 
afforded by the names of its authors."— Medical News, Philadelphia. 



CATALOGUE OF MEDICAL WORKS. 



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AN AMERICAN TEXT-BOOK ON THE THEORY AND 
PRACTICE OF MEDICINE. By American Teachers. Edited 
by William Pepper, M. D., LL.D., Provost and Professor of the Theory 
and Practice of Medicine and of Clinical Medicine in the University of 
Pennsylvania. Complete in two handsome royal-octavo volumes of about 
1000 pages each, with illustrations to elucidate the text wherever necessary. 
Price per Volume: Cloth, $5.00 net ; Sheep or Half-Morocco, $6.00 net. 

VOLUME I. CONTAINS: 



Hygiene. — Fevers (Ephemeral, Simple Con- 
tinued, Typhus, Typhoid, Epidemic Cerebro- 
spinal Meningitis, and Relapsing). — Scarlatina, 
Measles, Rotheln, Variola, Varioloid, Vaccinia, 
Varicella, Mumps, Whooping-cough, Anthrax, 



Hydrophobia, Trichinosis, Actinomycosis, Glan- 
ders, and Tetanus. — Tuberculosis, Scrofula, 
Syphilis, Diphtheria, Erysipelas, Malaria, Chol- 
era, and Yellow Fever. — Nervous, Muscular, and 
Mental Diseases. 



VOLUME II. CONTAINS; 



Urine (Chemistry and Microscopy). — Kidney 
and Lungs. — Air-passages (Larynx and Bronchi) 
and Pleura. — Pharynx, ([Esophagus, Stomach 
and Intestines (including Intestinal Parasites), 
Heart, Aorta, Arteries and Veins. — Peritoneum, 



Liver, and Pancreas. — Diathetic Diseases (Rheu- 
matism, Rheumatoid Arthritis, Gout, Lithaemia s 
and Diabetes). — Blood and Spleen. — Inflamma 
tion, Embolism, Thrombosis, Fever, and Bacte 
riology. 



The articles are not written as though addressed to students in lectures, but are 
exhaustive descriptions of diseases, with the newest facts as regards Causation, 
Symptomatology, Diagnosis, Prognosis, and Treatment, including a large number 
of approved formulae. The recent advances made in the study of the bacterial 
origin of various diseases are fully described, as well as the bearing of the know- 
ledge so gained upon prevention and cure. The subjects of Bacteriology as a 
whole and of Immunity are fully considered in a separate section. 

Methods of diagnosis are given the most minute and careful attention, thus 
enabling the reader to learn the very latest methods of investigation without con- 
sulting works specially devoted to the subject. 



CONTRIBUTORS 



Dr. J. S. Billings, Philadelphia. 
Francis Delafield, New York. 
Reginald H. Fitz, Boston. 
James W. Holland, Philadelphia. 
Henry M. Lyman, Chicago. 
William Osier, Baltimore. 



Dr. William Pepper, Philadelphia. 

W. Gilman Thompson, New York. 
W. H. Welch, Baltimore. 
James T. Whittaker, Cincinnati. 
James C. Wilson, Philadelphia. 
Horatio C. Wood, Philadelphia. 



" We reviewed the first volume of this work, and said : ' It is undoubtedly one of the best text' 
books on the practice of medicine which we possess.' A consideration of the second and last 
volume leads us to modify that verdict and to say that the completed work is, in our opinion, the 
BEST of its kind it has ever been our fortune to see. It is complete, thorough, accurate, and clear. 
It is well written, well arranged, well printed, well illustrated, and well bound. It is a model of 
what the modern text-book should be."- — New York Medical Journal. 

" A library upon modern medical art. The work must promote the wider diffusion of 30und 
knowledge." — American Lancet. 

" A trusty counsellor for the practitioner or senior student, on which he may implicitly rely."— 
Edinburgh Medical Journal. 



W. B. SAUNDERS' ILLUSTRATED 



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AN AMERICAN TEXT-BOOK OF THE DISEASES OF CHIL- 
DREN. By American Teachers. Edited by Louis Starr, M. D., 
assisted by Thompson S. Westcott, M. D. In one handsome royal-8vo vol 
ume of 1 1 90 pages, profusely illustrated with wood-cuts, half-tone and colored 
plates. Prices: Cloth, $7.00 net; Sheep or Half-Morocco, $8.00 net. 

The plan of this work embraces a series of original articles written by some 
sixty well-known psediatrists, representing collectively the teachings of the most 
prominent medical schools and colleges of America. The work is intended to be 
a practical book, suitable for constant and handy reference by the practitioner 
and the advanced student. 

One decided innovation is the large number of authors, nearly every article 
being contributed by, a specialist in the line on which he writes. This, while 
entailing considerable labor upon the editors, has resulted in the publication of a 

WOrk THOROUGHLY NEW AND ABREAST OF THE TIMES. 

Especial attention has been given to the consideration of the latest accepted 
teaching upon the etiology, symptoms, pathology, diagnosis, and treatment of the 
disorders of children, with the introduction of many special formulae and thera- 
peutic procedures. 

Special chapters embrace at unusual length the Diseases of the Eye, Ear, Nose 
and Throat, and the Skin ; while the introductory chapters cover fully the important 
subjects of Diet, Hygiene, Exercise, Bathing, and the Chemistry of Food. Trache- 
otomy, Intubation, Circumcision, and such minor surgical procedures coming 
within the province of the medical practitioner, are carefully considered. 

CONTRIBUTORS: 



Dr. S. S. Adams, Washington. 

John Ashhurst, Jr., Philadelphia. 
A. D. Blackader, Montreal, Canada. 
Dillon Brown, New York. 
Edward M. Buckingham, Boston. 
Charles W. Burr, Philadelphia. 
W. E. Casselberry, Chicago. 
Henry Dwight Chapin, New York. 
W. S. Christopher, Chicago. 
Archibald Church, Chicago. 
Floyd M. Crandall, New York. 
Andrew F. Currier, New York. 
Roland G. Curtin, Philadelphia. 
J. M. DaCosta, Philadelphia. 
I. N. Danforth, Chicago. 
Edward P. Davis, Philadelphia. 
John B. Deaver, Philadelphia. 
G. E. de Schweinitz, Philadelphia. 
John Doming, New York. 
Charles Warrington Earle, Chicago. 
Wm. A. Edwards, San Diego, Cal. 
F. Forchheimer, Cincinnati. 
J. Henry Fruitnight, New York. 
Landon Carter Gray, New York. 
J. P. Crozer Griffith, Philadelphia. 
W. A. Hardaway, St. Louis. 
M. P. Hatfield, Chicago. 
Barton Cooke Hirst, Philadelphia. 
H. Illoway, Cincinnati. 
Henry Jackson, Boston. 
Charles G. Jennings, Detroit. 
Henry Koplik, New York. 



Dr. Thomas S. Latimer, Baltimore. 
Albert R. Leeds, Hoboken, N. J. 
J. Hendrie Lloyd, Philadelphia. 
George Roe Lockwood, New York. 
Henry M. Lyman, Chicago. 
Francis T. Miles, Baltimore. 
Charles K. Mills, Philadelphia. 
John H. Musser, Philadelphia. 
Thomas R. Neilson, Philadelphia. 
W. P. Northrup, New York. 
William Osier, Baltimore. 
Frederick A. Packard, Philadelphia. 
William Pepper, Philadelphia. 
Frederick Peterson, New York. 
W. T. Plant, Syracuse, New York. 
William M. Powell, Atlantic City. 
B. Alexander Randall, Philadelphia. 
Edward O. Shakespeare, Philadelphia. 
F. C. Shattuck, Boston. 
J. Lewis Smith, New York. 
Louis Starr, Philadelphia. 
M. Allen Starr, New York. 
J. Madison Taylor, Philadelphia. 
Charles W. Townsend, Boston. 
James Tyson, Philadelphia. 
W. S. Thayer, Baltimore. 
Victor C. Vaughan, Ann Arbor, Mich. 
Thompson S. Westcott, Philadelphia 
Henry R. Wharton, Philadelphia. 
J. William White, Philadelphia. 
J. C. Wilson, Philadelphia. 



CATALOGUE OF MEDICAL WORKS. 



For Sale by Subscription. 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY, MEDICAL 
AND SURGICAL, for the use of Students and Practitioner 

Edited by J. M. Baldy, M. D. Forming a handsome royal-octavo volume, 
with 360 illustrations in text and 37 colored and half-tone plates. Prices: 
Cloth, $6.00 net; Sheep or Half-Morocco, $7.00 net. 



understanding of the text, have been omitted, 



In this volume all anatomical descriptions, excepting those essential to a clear 

the illustrations being largely 
depended upon to eluci- 
date the anatomy of the 
parts. This work, which 
is thoroughly practical in 
its teachings, is intended, 
as its title implies, to be 
a working text-book for 
physicians and students. 
A clear line of treatment 
has been laid down in 
every case, and although 
no attempt has been made 
to discuss mooted points, 
still the most important 
of these have been noted 
and explained. The ope- 
rations recommended are 
fully illustrated, so that 
the reader, having a pic- 
ture of the procedure de- 
scribed in the text under 
his eye, cannot fail to 
grasp the idea. All ex- 
traneous matter and dis- 
cussions have been care- 
fully excluded, the attempt 
being made to allow no 
The subject-matter is brought up to date 

at every point, and the work is as nearly as possible the combined opinions of the 

ten specialists who figure as the authors. 

The work is well illustrated throughout with wood-cuts, half-tone and colored 

plates, mostly selected from the authors' private collections. 




Specimen Illustration. 



unnecessary details to cumber the text. 



CONTRIBUTORS 



Dr. Henry T. Byford. 
John M. Baldy. 
Edwin Cragin. 
J. H. Etheridge. 
"William Goodell. 



Dr. 



Howard A. Kelly. 
Florian Krug. 
E. E. Montgomery. 
William R. Pryor. 
George M. Tuttle. 



" The most notable contribution to gynecological literature since 1887, • • • • an d the most com- 
plete exponent of gynecology which we have. No subject seems to have been neglected, .... and 
the gynecologist and surgeon and the general practitioner, who has any desire to practise diseases 
of women, will find it of practical value. In the matter of illustrations and plates the book sur- 
passes anything we have seen." — Boston Medical and Surgical Journal. 



io W. B. SAUNDERS' ILLUSTRATED 

A NEW PRONOUNCING DICTIONARY OF MEDICINE, with 
Phonetic Pronunciation, Accentuation, Etymology, etc. By John 
M. Keating, M. D., LL.D., Fellow of the College of Physicians of Phila- 
delphia; Vice-President of the American Pediatric Society; Ex-President 
of the Association of Life Insurance Medical Directors ; Editor " Cyclopaedia 
of the Diseases of Children," etc. ; and Henry Hamilton, Author of a " A, 
New Translation of Virgil's ^Eneid into English Rhyme;" Co-Author of 
"Saunders' Medical Lexicon," etc. ; with the Collaboration of J. Chalmers 
DaCosta, M. D., and Frederick A. Packard, M. D. With an Appendix, 
containing Important Tables of Bacilli, Micrococci, Leucomaines, Ptomaines ; 
Drugs and Materials used in Antiseptic Surgery ; Poisons and their Antidotes ; 
Weights and Measures ; Thermometric Scales ; New Official and Unofficial 
Drugs, etc. One volume of over 800 pages. Second Revised Edition. 
Prices : Cloth, $5.00 ; Sheep or Half-Morocco, $6.00 net ; Half- Russia, $6.50 
net, with Denison's Patent Ready- Reference Index ; without Patent Index, 
Cloth, $4.00 net; Sheep or Half-Morocco, $5.00 net. 

" I am much pleased with Keating's Dictionary, and shall take pleasure in recommending it 
to my classes." 

Henry M. Lyman, M. D., 
Professor of Principles and Practice of Medicine, Rush Medical College, Chicago, El. 

" I am convinced that it will be a very valuable adjunct to my study-table, convenient in size 
and sufficiently full for ordinary use." 

C. A. Lindsley, M. D., 
Professor of Theory and Practice of Medicine, Medical Dept. Yale University ; 

Secretary Connecticut State Board of Health, New Haven-, Conn. 

MEDICAL DIAGNOSIS. By Dr. Oswald Vierordt, Professor of Medi- 
cine at the University of Heidelberg. Translated, with additions, from the 
Second Enlarged German Edition, with the author's permission, by Francis 
H. Stuart, A. M., M. D. Third and Revised Edition. In one handsome 
royal-octavo volume of 700 pages, 178 fine wood-cuts in text, many of which 
are in colors. Prices: Cloth, $4.00 net; Sheep or Half-Morocco, $5.00 net; 
Half- Russia, $5.50 net. 

In this work, as in no other hitherto published, are given full and accurate 
explanations of the phenomena observed at the bedside. It is distinctly a clinical 
work by a master teacher, characterized by thoroughness, fulness, and accuracy. 
It is a mine of information upon the points that are so often passed over without 
explanation. Especial attention has been given to the germ-theory as a factor in 
the origin of disease. 

This valuable work is now published in German, English, Russian, and Italian. 
The issue of a third American edition within two years indicates the favor with which 
it has been received by the profession. 

" Rarely is a book published with which a reviewer can find so little fault as with the volume 
before us. All the chapters are full, and leave little to be desired by the reader. Each particular 
item in the consideration of an organ or apparatus, which is necessary to determine a diagnosis of 
any disease of that organ, is mentioned ; nothing seems forgotten. The chapters on diseases of the 
circulatory and digestive apparatus and nervous system are especially full and valuable. Not- 
withstanding a few minor errors in translating, which are of small importance to the accuracy 
of the rest of the volume, the reviewer would repeat that the book is one of the best — probably, 
the best — which has fallen into his hands. An excellent and comprehensive index of nearly one 
hundred pages closes the volume." — University Medical Magazine, Philadelphia. 



CATALOGUE OF MEDICAL WORKS. 



PATHOLOGY AND SURGICAL TREATMENT OF TUMORS. 

By N. Senn, M. D., Ph. D., LL. D., Professor of Surgery and of Clinical 
Surgery, Rush Medical College ; Professor of Surgery, Chicago Polyclinic ; 
Attending Surgeon to Presbyterian Hospital; Surgeon-in- Chief, St. Joseph's 
Hospital, Chicago. 710 pages, 515 engravings, including full-page colored 
plates. Prices: Cloth, $6.00 net ; Half-Morocco, $7.00 net. 

Books specially devoted to this subject are few, and in our text-books and 
systems of surgery this part of surgical pathology is usually condensed to a degree 
incompatible with its scientific and clinical importance. The author spent many 
years in collecting the material for this work, and has taken great pains to present 
it in a manner that should prove useful as a text-book for the student, a work 
of reference for the busy practitioner, and a reliable, safe guide for the surgeon. 
The more difficult operations are fully described and illustrated. More than one 
hundred of the illustrations are original, while the remainder were selected from 
books and medical journals not readily accessible to the student and the general 
practitioner. 

" The appearance of such a work is most opportune. ... In design and execution the work is 
such as will appeal to every student who appreciates the logical examination of facts and the prac- 
tical exemplification of well-digested clinical observation." — Medical Record, New York. 

" The most exhaustive of any recent book in English on this subject. It is well illustrated, and 
will doubtless remain as the principal monograph on the subject in our language for some years. 
The book is handsomely illustrated and printed, .... and the author has given a notable and 
lasting contribution to surgery." — Journal of American Medical Association, Chicago. 

SURGICAL PATHOLOGY AND THERAPEUTICS. By John 
Collins Warren, M. D., LL. D., Professor of Surgery, Medical Depart- 
ment Harvard University ; Surgeon to the Massachusetts General Hospital, 
etc. A handsome octavo volume of 832 pages, with 136 relief and litho- 
graphic illustrations, ^ of which are printed in colors, and all of which were 
drawn by William J. Kaula from original specimens. Prices: Cloth, $6.00 
net; Half-Morocco, $7.00 net. 

" The volume is for the bedside, the amphitheatre, and the ward. It deals 
with things not as we see them through the microscope alone, but as the practitioner 
sees their effect in his patients ; not only as they appear in and affect culture- 
media, but also as they influence the human body ; and, following up the demon- 
strations of the nature of diseases, the author points out their logical treatment" 
(New York Medical Journal}. "Indeed, the volume maybe termed a modern 
medical classic, for such is the position to which it has already risen ' ' {Medical 
Age, Detroit), " and is the handsomest specimen of bookmaking * * * that has 
ever been issued from the American medical press ' ' (American Journal of the 
Medical Sciences, Philadelphia). 

Without Exception, the Illustrations are the Best ever Seen in a "Work of 

this Kind. 

" A most striking and very excellent feature of this book is its illustrations. Without exception, 
from the point of accuracy and artistic merit, they are the best ever seen in~ a work of this kind. 
* * -* Many of those representing microscopic pictures are so perfect in their coloring and detail as 
almost to give the beholder the impression that he is looking down the barrel of a microscope at a 
well-mounted section." — Annals of Surgery, Philadelphia. 



W. B. SAUNDERS' ILLUSTRATED 



AUTOBIOGRAPHY OF SAMUEL D. GROSS, M. D., Emeritus 
Professor of Surgery in the Jefferson Medical College of Philadelphia, with 
Reminiscences of His Times and Contemporaries. Edited by his Sons, 
Samuel W. Gross, M. D., LL.D., late Professor of Principles of Surgery 
and of Clinical Surgery in the Jefferson Medical College, and A. Haller 
Gross, A. M., of the Philadelphia Bar. Preceded by a Memoir of Dr. Gross, 
by the late Austin Flint, M. D., LL.D. In two handsome volumes, each con- 
taining over 400 pages, demy 8vo, extra cloth, gilt tops, with fine Frontis- 
piece engraved on steel. Price, $5.00 net. 

This autobiography, which was continued by the late eminent surgeon until 
within three months before his death, contains a full and accurate history of his 
early struggles, trials, and subsequent successes, told in a singularly interesting 
and charming manner, and embraces short and graphic pen-portraits of many of 
the most distinguished men — surgeons, physicians, divines, lawyers, statesmen, 
scientists, etc. — with whom he was brought in contact in America and in Europe j 
the whole forming a retrospect of more than three-quarters of a century. 

" Dr. Gross . . . was perhaps the most eminent exponent of medical science that America has yet 
produced. His Autobiography, related as it is with a fulness and completeness seldom to be found 
in such works, is an interesting and valuable book. He comments on many things, especially, of 
course, on Medical Men and Medical Practice, in a very interesting way. Details of profes- 
sional life have also much in them that will be new." — The Spectator, London, England. 

THE PICTORIAL ATLAS OF SKIN DISEASES AND SYPH- 
ILITIC AFFECTIONS (American Edition). Translation from the 
French. Edited by J. J. Pringle, M. B., F. R. C. P., Assistant Physician 
to, and Physician to the department for Diseases of the Skin at, the Middle- 
sex Hospital, London. Photo-lithochromes from the famous models of der- 
matological and syphilitic cases in the Museum of the Saint-Louis Hospital, 
Paris, with explanatory wood-cuts and text. In 12 Parts, at $3.00 per Part. 
Parts 1 to 8 now ready. 

" The plates are beautifully executed." — Jonathan Hutchinson, M. D. (London Hospital). 

" I strongly recommend this Atlas. The plates are exceedingly well executed, and will be 
of great value to all studying dermatology." — Stephen Mackenzie, M. D. (London Hospital). 

" The plates in this Atlas are remarkably accurate and artistic reproductions of typical ex- 
amples of skin disease. The work will be of great value to the practitioner and student." — 
William Anderson, M. D. (St. Thomas Hospital). 

" If the succeeding parts of this Atlas are to be similar to Part 1, now before us, we have no 
hesitation in cordially recommending it to the favorable notice of our readers as one of the finest 
dermatological atlases with which we are acquainted." — Glasgow Medical Journal, Aug., 1895. 

" Of all the atlases of skin diseases which have been published in recent years, the present one 
promises to be of greatest interest and value, especially from the standpoint of the general practi- 
tioner." — American Medico- Surgical Bulletin, Feb. 22, 1 896. 

" The introduction of explanatory wood-cuts in the text is a novel and most important feature 
which greatly furthers the easier understanding of the excellent plates, than which nothing, we ven- 
ture to say, has been seen better in point of correctness, beauty, and general merit." — Neiu York 
Medical Journal, Feb. 15, 1 896. 

" An interesting feature of the Atlas is the descriptive text, which is written for each picture by 
the physician who treated the case or at whose instigation the models have been made. We pre- 
dict for this truly beautiful work a large circulation in all parts of the medical world where the 
names St. Louis and Baretta have preceded it." — Medical Record, N. Y., Feb. 1, 1896. 



. CATALOGUE OF MEDICAL WORKS. 13 

PRACTICAL POINTS IN NURSING. For Nurses in Private 
Practice. By Emily A. M. Stoney, Graduate of the Training-School for 
Nurses, Lawrence, Mass. ; Superintendent of the Training-School for Nurses, 
Carney Hospital, South Boston, Mass. 456 pages, handsomely illustrated 
with 73 engravings in the text, and 9 colored and half-tone plates. Cloth. 
Price, $1.75 net. 

In this volume the author explains, in popular language and in the shortest 
possible form, the entire range of private nursing as distinguished from hospital 
nursing, and the nurse is instructed how best to meet the various emergencies of 
medical and surgical cases when distant from medical or surgical aid or when 
thrown on her own resources. 

An especially valuable feature of the work will be found in the directions to 
the nurse how to improvise everything ordinarily needed in the sick-room, where 
the embarrassment of the nurse, owing to the want of proper appliances, is fre- 
quently extreme. 

The work has been logically divided into the following sections : 

I. The Nurse : her responsibilities, qualifications, equipment, etc. 
II. The Sick-Room : its selection, preparation, and management. 

III. The Patient : duties of the nurse in medical, surgical, obstetric, and gyne- 

cologic cases. 

IV. Nursing in Accidents and Emergencies. 
V. Nursing in Special Medical Cases. 

VI. Nursing of the New-born and Sick Children. 
VII. Physiology and Descriptive Anatomy. 

The Appendix contains much information in compact form that will be found 
of great value to the nurse, including Rules for Feeding the Sick ; Recipes for 
Invalid Foods and Beverages ; Tables of Weights and Measures ; Table for Com- 
puting the Date of Labor ; List of Abbreviations ; Dose-List ; and a full and com- 
plete Glossary of Medical Terms and Nursing Treatment. 

" There are few books intended for non-professional readers which can be so cordially endorsed 
by a medical journal as can this one.'' — Therapeutic Gazette, Aug. 15, 1896. 

" This is a well-written, eminently practical volume, which covers the entire range of private 
nursing as distinguished from hospital nursing, and instructs the nurse how best to meet the various 
emergencies which may arise and how to prepare everything ordinarily needed in the illness of her 
patient." — American Journal of Obstetrics and Diseases of Women and Children, Aug., 1896. 

" It is a work that the physician can place in the hands of his private nurses with the assurance 
of benefit."— Ohio Medical Journal, Aug., 1896. 

A TEXT-BOOK OF BACTERIOLOGY, including the Etiology and 

Prevention of Infective Diseases and an account of Yeasts and 
Moulds, Haematozoa, and Psorosperms. By Edgar M. Crook- 
shank, M. B., Professor of Comparative Pathology and Bacteriology, King's 
College, London. A handsome octavo volume of 700 pages, illustrated with 
273 engravings in the text, and 22 original and colored plates. Price, 
$6.50 net. 

This book, though nominally a Fourth Edition of Professor Crookshank's 
"Manual of Bacteriology," is practically a new work, the old one having 
been reconstructed, greatly enlarged, revised throughout, and largely rewritten, 
forming a text-book for the Bacteriological Laboratory, for Medical Officers 
of Health, and for Veterinary Inspectors. 




Specimen Illustration. 



14 W. B. SAUNDERS' ILLUSTRATED 

DISEASES OF THE EYE. A Hand-Book of Ophthalmic Practice. 

By G. E. de Schweinitz, M. D., Professor of Ophthalmology in the Jeffer- 
son Medical College, Philadelphia, etc. A handsome royal-octavo volume 
of 679 pages, with 256 fine illustrations, many of which are original, and 2 
chromo-lithographic plates. Prices: Cloth, #4.00 net; Sheep or Half- 
Morocco, $5.00 net. 

The object of this work is to present to the student, and to the practitioner who 

is beginning work in the fields of ophthal- 
mology, a plain description of the optical 
defects and diseases of the eye. To this 
end special attention has been paid to the 
clinical side of the question ; and the 
method of examination, the symptoma- 
tology leading to a diagnosis, and the 
treatment of the various ocular defects 
have been brought into prominence. 

SECOND EDITION, REVISED AND 
GREATLY ENLARGED. 

The entire book has been thoroughly 
revised. In addition to this general re- 
vision, special paragraphs on the following 
new matter have been introduced : Filamentous Keratitis, Blood-staining of the 
Cornea, Essential Phthisis Bulbi, Foreign Bodies in the Lens, Circinate Retinitis, 
Symmetrical Changes at the Macula Lutea in Infancy, Hyaline Bodies in the 
Papilla, Monocular Diplopia, Subconjunctival Injections of Germicides, Infiltra- 
tion-Anaesthesia, and Sterilization of Collyria. Brief mention of Ophthalmia 
Nodosa, Electric Ophthalmia, and Angioid Streaks in the Retina also finds place. 
An Appendix has been added, containing a full description of the method of deter- 
mining the corneal astigmatism with the ophthalmometer of Javal and Schiotz, 
and the rotations of the eyes with the tropometer of Stevens. The chapter on 
Operations has been enlarged and rewritten. 

"A clearly written, comprehensive manual. . . . One which we can commend to students as a 
reliable text-book, written with an evident knowledge of the wants of those entering upon the study 
of this special branch of medical science." — British Medical Journal. 

" The work is characterized by a lucidity of expression which leaves the reader in no doubt as 
to the meaning of the language employed. . . . We know of no work in which these diseases are 
dealt with more satisfactorily, and indications for treatment more clearly given, and in harmony with 
the practice of the most advanced ophthalmologists." — Maritime Medical News. 

" It is hardly too much to say that for the student and practitioner beginning the study of 
Ophthalmology, it is the best single volume at present published." — Medical News. 

" The latest and one of the best books on Ophthalmology. The book is thoroughly up to date, 
and is certainly a work which not only commends itself to the student, but is a ready reference for 
the busy practitioner." — Internatio?ial Medical Magazine. 

FEEDING IN EARLY INFANCY. By Arthur V. Meigs, M. D. 
Bound in limp cloth, flush edges. Price, 25 cents net. 

Synopsis : Analyses of Milk — Importance of the Subject of Feeding in Early 
Infancy — Proportion of Casein and Sugar in Human Milk — Time to Begin Arti- 
ficial Feeding of Infants— Amount of Food to be Administered at Each Feeding — 
Intervals between Feedings— Increase in Amount of Food at Different Periods of 
Infant Development — Un -suitableness of Condensed Milk as a Substitute for Moth- 
er's Milk — Objections to Sterilization or "Pasteurization" of Milk — Advances 
made in the Method of Artificial Feeding of Infants. 



CATALOGUE OF MEDICAL WORKS. 15 

A TEXT-BOOK OF HISTOLOGY, DESCRIPTIVE AND PRAC- 
TICAL. For the Use of Students. By Arthur Clarkson, M. B., 
C. M., Edin., formerly Demonstrator of Physiology in the Owen's College, 
Manchester; late Demonstrator of Physiology in the Yorkshire College, 
Leeds. Large 8vo, 554 pages, with 22 engravings in the text, and 174 
beautifully colored original illustrations. Price, strongly bound in Cloth, 
$6.00 net. 

The purpose of the writer in this work has been to furnish the student of His- 
tology, in one volume, with both the descriptive and the practical part of the 
science. The first two chapters are devoted to the consideration of the general 
methods of Histology ; subsequently, in each chapter, the structure of the tissue 
or organ is first systematically described, the student is then taken tutorially over 
the specimens illustrating it^and, finally, an appendix affords a short note of the 
methods of preparation. 

TEXT-BOOK UPON THE PATHOGENIC BACTERIA. Spe- 
cially written for Students of Medicine. By Joseph McFarland, 
M. D., Professor of Pathology and Bacteriology in the Medico- Chirurgical 
College of Philadelphia, etc. 359 pages, finely illustrated. Cloth. Price, 
$2.50 net. 

The book presents a concise account of the technical procedures necessary in 
the study of Bacteriology. It describes the life-history of pathogenic bacteria, and 
the pathological lesions following invasions. 

The work is intended to be a text-book for the medical student and for the 
practitioner who has had no recent laboratory training in this department of med- 
ical science. The instructions given as to needed apparatus, cultures, stainings, 
microscopic examinations, etc. are ample for the student's needs, and will afford 
to the physician much information that will interest and profit him. 

" The author has succeeded admirably in presenting the essential details of bacteriological 
technics, together with a judiciously chosen summary of our present knowledge of pathogenic bac- 
teria. . . . The work, we think, should have a wide circulation among English-speaking students 
of medicine." — 7V. Y. Medical Journal, April 4, 1896. 

A MANUAL OF PHYSIOLOGY, with Practical Exercises. For 

Students and Practitioners. By G. N. Stewart, M. A., M. D., D. Sc, 

lately Examiner in Physiology, University of Aberdeen, and of the New 
Museums, Cambridge University ; Professor of Physiology in the Western 
Reserve University, Cleveland, Ohio. Handsome octavo volume of 800 
pages, with 278 illustrations in the text, and 5 colored plates. Price, 
Cloth, $3.50 net. 

" It will make its way by sheer force of merit, and amply deserves to do so. It is one of the 
very best English text-books on the subject." — lancet. 

"Of the many text-books of physiology published, we do not know of one that so nearly 
comes up to the ideal as does Prof. Stewart's volume." — British Medical Journal. 

WATER AND WATER SUPPLIES. By John C. Thresh, D. Sc, 
M. B., D. P. H., Lecturer on Public Health, King's College, London; 
Editor of the "Journal of State Medicine," etc. i2mo, 438 pages, illus- 
trated. Handsomely bound in Cloth, with gold side and back stamps 
Price, $2.25 net. 



1 6 W. B. SAUNDERS' ILLUSTRATED 

ARCHIVES OF CLINICAL SKIAGRAPHY. By Sydney Rowland, 
B. A., Camb., late Scholar of Downing College, Cambridge, and Shuter 
Scholar of St. Bartholomew's Hospital, London ; Special Commissioner to 
"British Medical Journal" for the Investigation of the Applications of the 
New Photography to Medicine and Surgery. A series of collotype illustra- 
tions, with descriptive text, illustrating the applications of the New Photog- 
raphy to Medicine and Surgery. Price, per Part, $1.00. Parts I. to III. 
now ready. 

The object of this publication is to put on record in permanent form some of 
the most striking applications of the new photography to the needs of Medicine 
and Surgery. 

The progress of this new art has been so rapid that, although Prof. Rontgen's 
discovery is only a thing of yesterday, it has already taken its place among the 
approved and accepted aids to diagnosis. 

ESSENTIALS OF ANATOMY AND MANUAL OF PRACTICAL 
DISSECTION, containing "Hints on Dissection." By Charles B. 
Nancrede, M. D., Professor of Surgery and Clinical Surgery in the Uni- 
versity of Michigan, Ann Arbor; Corresponding Member of the Royal 
Academy of Medicine, Rome, Italy; late Surgeon Jefferson Medical Col- 
lege, etc. Fourth and revised edition. Post 8vo, over 500 pages, with 
handsome full-page lithographic plates in colors, and over 200 illustrations. 
Price : Extra Cloth (or Oilcloth for the dissection-room), $2.00 net. 

No pains nor expense has been spared to make this work the most exhaustive 
yet concise Student's Manual of Anatomy and Dissection ever published, either in 
America or in Europe. The colored plates are designed to aid the student in 
dissecting the muscles, arteries, veins, and nerves. The wood-cuts have all been 
specially drawn and engraved, and an Appendix added containing 60 illustrations 
representing the structure of the entire human skeleton, the whole being based 
on the eleventh edition of Gray's Anatomy. 

A MANUAL OF PRACTICE OF MEDICINE. By A. A. Stevens, 
A. M., M. D., Instructor of Physical Diagnosis in the University of Pennsyl- 
vania, and Demonstrator of Pathology in the Woman's Medical College of 
Philadelphia. Specially intended for students preparing for graduation and 
1 hospital examinations. Post 8vo, 512 pages. Illustrated. Price, $2.50. 
FOURTH EDITION, REVISED AND ENLARGED. 
Contributions to the science of medicine have poured in so rapidly during the 
last quarter of a century that it is well-nigh impossible for the student, with the 
limited time at his disposal, to master elaborate treatises or to cull from them that 
knowledge which is absolutely essential. From an extended experience in teach- 
ing, the author has been enabled, by classification, to group allied symptoms, and 
by the elimination of theories and redundant explanations to bring within a com- 
paratively small compass a complete outline of the practice of medicine. 
TEMPERATURE CHART. Prepared by D. T. Laine, M. D. Size 
8x 131^ inches. Price, per pad of 25 charts, 50 cents net. 

A conveniently arranged chart for recording Temperature, with columns for daily amounts of 
Urinary and Fecal Excretions, Food, Remarks, etc. On the back of each chart is given in full the 
method of Brand in the treatment of Typhoid Fever. 



CATALOGUE OF MEDICAL WORKS. 17 

MANUAL OF MATERIA MEDICA AND THERAPEUTICS. By 

A. A. Stevens, A. M., M. D., Instructor of Physical Diagnosis in the Uni- 
versity of Pennsylvania, and Demonstrator of Pathology in the Woman's 
Medical College of Philadelphia. 445 pages. Price, Cloth, $2.25. 

SECOND EDITION, REVISED. 

This wholly new volume, which is based on the last edition of the Pharma- 
copoeia, comprehends the following sections : Physiological Action of Drugs ; 
Drugs ; Remedial Measures other than Drugs ; Applied Therapeutics ; Incom- 
patibility in Prescriptions ; Table of Doses ; Index of Drugs ; and Index of Dis- 
eases ; the treatment being elucidated by more than two hundred formulae. 

NOTES ON THE NEWER REMEDIES: their Therapeutic Appli- 
cations and Modes of Administration. By David Cerna, M.D., Ph.D., 
Demonstrator of and Lecturer on Experimental Therapeutics in the Univer- 
sity of Pennsylvania. Post 8vo, 253 pages. Price, $1.25. 

SECOND EDITION, RE-WRITTEN AND GREATLY ENLARGED. 

The work takes up in alphabetical order all the newer remedies, giving their 
physical properties, solubility, therapeutic applications, administration, and chem- 
ical formula. 

SAUNDERS' POCKET MEDICAL FORMULARY. By William 
M. Powell, M. D., Attending Physician to the Mercer House for Invalid 
Women at Atlantic City. Containing 1750 Formulae, selected from several 
hundred of the best-known authorities. Forming a handsome and convenient 
pocket companion of nearly 300 printed pages, with blank leaves for additions; 
with an Appendix containing Posological Table, Formulae and Doses for 
Hypodermic Medication, Poisons and their Antidotes, Diameters of the 
Female Pelvis and Fcetal Head, Obstetrical Table, Diet List for Various Dis- 
eases, Materials and Drugs used in Antiseptic Surgery, Treatment of Asphyxia 
from Drowning, Surgical Remembrancer, Tables of Incompatibles, Eruptive 
Fevers, Weights and Measures, etc. Third edition, revised and greatly 
enlarged. Handsomely bound in morocco, with side index, wallet, and flap. 
Price, $1.75 net. 

" This little book, that can be conveniently carried in the pocket, contains an immense amount 
of material. It is very useful, and as the name of the author of each prescription is given is 
unusually reliable." — New York Medical Record. 

SAUNDERS' POCKET MEDICAL LEXICON; or, Dictionary of 
Terms and Words used in Medicine and Surgery. By John M. 
Keating, M. D., Editor of "Cyclopaedia of Diseases of Children," etc.; 
Author of the " New Pronouncing Dictionary of Medicine," and Henry 
Hamilton, Author of "A New Translation of Virgil's yEneid into English 
Verse;" Co- Author of a "New Pronouncing Dictionary of Medicine." 
A new and revised edition. 32mo, 282 pages. Prices: Cloth, 75 cents; 
Leather Tucks, #1.00. 

" Remarkably accurate in terminology, accentuation, and definition."— Journal of American 

Medical Association. 



IS W. B. SAUNDERS' ILLUSTRATED 

DISEASES OF WOMEN. By Henry J. Garrigues, A. M., M. D., Pro- 
fessor of Obstetrics in the New York Post- Graduate Medical School and Hos- 
pital ; Gynaecologist to St. Mark's Hospital, and to the German Dispensary, 
etc., New York City. One octavo volume of nearly 700 pages, illustrated 
by 300 wood-cuts and colored plates. Prices: Cloth, $4.00 net; Sheep, 
$5.00 net. 

A practical work on gynecology for the use of students and practitioners, 
written in a terse and concise manner. The importance of a thorough knowledge 
of the anatomy of the female pelvic organs has been fully recognized by the 
author, and considerable space has been devoted to the subject. The chapters on 
Operations and on Treatment are thoroughly modern, and are based upon the 
large hospital and private practice of the author. The text is elucidated by a 
large number of illustrations and colored plates, many of them being original, and 
forming a complete atlas for studying embryology and the anatomy of the female 
genitalia, besides exemplifying, whenever needed, morbid conditions, instruments, 
apparatus, and operations. 

EXCERPT OF CONTENTS. 

Development of the Female Genitals. — Anatomy of the Female Pelvic Organs. — Physiology. — 
Puberty. — Menstruation and Ovulation. — Copulation. — Fecundation. — The Climacteric. — Etiology 
in General. — Examinations in General. — Treatment in General. — Abnormal Menstruation and Me- 
trorrhagia. — Leucorrhea. — Diseases of the Vulva. — Diseases of the Perineum. — Diseases of the 
Vagina. — Diseases of the Uterus. — Diseases of the Fallopian Tubes. — Diseases of the Ovaries. — 
Diseases of the Pelvis. — Sterility. 

The reception accorded to this ■work has been most flattering". In the 
short period which has elapsed since its issue, it has been adopted and 
recommended as a text-book by more than 60 of the Medical Schools and 
Universities of the United States and Canada. 

" One of the best text-books for students and practitioners which has been published in the 
English language ; it is condensed, clear, and comprehensive. The profound learning and great 
clinical experience of the distinguished author find expression in this book in a most attractive and 
instructive form. Young practitioners, to whom experienced consultants may not be available, will 
find in this book invaluable counsel and help." 

Thad. A. Reamy, M. D., LL.D., 
Professor of Clinical Gynecology, Medical College of Ohio ; Gynecologist to the Good 
Sai?iaritan and to the Cincinnati Hospitals. 

ESSENTIALS OF PHYSICAL DIAGNOSIS OF THE THO- 
RAX. By Arthur M. Corwin, A. M., M. D., Demonstrator of Physical 
Diagnosis in the Rush Medical College, Chicago ; Attending Physician to 
the Central Free Dispensary, Department of Rhinology, Laryngology, and 
Diseases of the Chest. 200 pages. Illustrated. Cloth, flexible covers. 
Price, #1.25 net. 

This book was originally published for the use of students, but its rapid absorp- 
tion by the practitioner made it appear that a wider field had been reached. In 
this edition the author has added to his revision of the text a section setting forth 
the signs found in each of the diseases of the chest, thereby increasing its value to 
the general practitioner for post-graduate study. 

" It is excellent. The student who shall use it as his guide to the careful study of physical 
exploration upon normal and abnormal subjects can scarcely fail to acquire a good working know- 
ledge of the subject." — Philadelphia Polyclinic. 



CATALOGUE OF MEDICAL WORKS. 19 

SYLLABUS OF OBSTETRICAL LECTURES in the Medical 

Department, University of Pennsylvania. By Richard C. Norris, 
A. M., M. D., Demonstrator of Obstetrics in the University of Pennsylvania, 
Third edition, thoroughly revised and enlarged. Crown 8vo. Price, Cloth, 
interleaved for notes, $2.00 net. 

" This work is so far superior to others on the same subject that we take 
pleasure in calling attention briefly to its excellent features. It covers the subject 
thoroughly, and will prove invaluable both to the student and the practitioner. 
The author has introduced a number of valuable hints which would only occur 
to one who was himself an experienced teacher of obstetrics. The subject-matter 
is clear, forcible, and modern. We are especially pleased with the portion devoted 
to the practical duties of the accoucheur, care of the child, etc. The paragraphs 
on antiseptics are admirable ; there is no doubtful tone in the directions given. 
No details are regarded as unimportant ; no minor matters omitted. We venture 
to say that even the old practitioner will find useful hints in this direction which 
he cannot afford to despise." — Medical Record. 

A SYLLABUS OF GYNECOLOGY, arranged in conformity with 
" An American Text-Book of Gynecology." By J. W. Long, M. D., 
Professor of Diseases of Women and Children, Medical College of Virginia, 
etc. Price, Cloth (interleaved), $1.00 net. 

Based upon the teaching and methods laid down in the larger work, this will 
not only be useful as a supplementary volume, but to those who do not already 
possess the Text-Book it will also have an independent value as an aid to the prac- 
titioner in gynecological work, and to the student as a guide in the lecture-room, 
as the subject is presented in a manner systematic, succinct, and practical. 

A SYLLABUS OF LECTURES ON THE PRACTICE OF SUR- 
GERY, arranged in conformity with "An American Text-Book 
of Surgery." By Nicholas Senn, M. D., Ph. D., Professor of Surgery in 
Rush Medical College, Chicago, and in the Chicago Polyclinic. Price, $2.00. 

This excellent work of its eminent author, himself one of the contributors to 
"An American Text-Book of Surgery," will prove of exceptional value to the 
advanced student who has adopted that work as his text-book. It is not only the 
syllabus of an unrivalled course of surgical practice, but it is also an epitome of, 
or supplement to the larger work. 

AN OPERATION BLANK, with Lists of Instruments, etc. re- 
quired in Various Operations. Prepared by W. W. Keen, M. D., 
LL.D., Professor of Principles of Surgery in the Jefferson Medical College, 
Philadelphia. Price per pad, containing Blanks for fifty operations, 50 
cents net. 

SECOND EDITION, REVISED FORM. 

A convenient blank (suitable for all operations), giving complete instructions 
regarding necessary preparation of patient, etc., with a full list of dressings and 
medicines to be employed. On the back of each blank is a list of instruments 
used — viz. general instruments, etc., required for all operations; and special in- 
struments for surgery of the brain and spine, mouth and throat, abdomen, rectum, 
male and female genito-urinary organs, the bones, etc. The whole forming a neat 
pad, arranged for hanging on the wall of a surgeon's office or in the hospital 
operating-room. 



20 



W. B. SAUNDERS' ILLUSTRATED 



LABORATORY EXERCISES IN BOTANY. By Edson S. Bastin, 
M. A., Professor of Materia Medica and Botany in the Philadelphia Col- 
lege of Pharmacy. Octavo volume of 536 pages, with 87 plates. Price, 
Cloth, $2.50. 

This work is. intended for the beginner and the advanced student, and it fully 
-covers the structure of flowering plants, roots, ordinary stems, rhizomes, tubers, 
bulbs, leaves, flowers, fruits, and seeds. Particular attention is given to the gross 
and microscopical structure of plants, and to those used in medicine. The illus- 
trations fully elucidate the text, and the complete index facilitates reference. 




Trailing Arbutus (Epigea repens). 
Specimen Illustration. 



LABORATORY GUIDE FOR THE BACTERIOLOGIST. By 

Langdon Frothingham, M. D. V., Assistant in Bacteriology and Veterinary 
Science, Sheffield Scientific School, Yale University. Illustrated. Price, 
Cloth, 75 cents. 

The technical methods involved in bacteria-culture, methods of staining, and 
microscopical study are fully described and arranged as simply and concisely as 
possible. The book is especially intended for use in laboratory work. 



OBSTETRIC ACCIDENTS, EMERGENCIES, AND OPERA- 
TIONS. By L. Ch. Boisliniere, M. D., late Emeritus Professor of Ob- 
stetrics in the St. Louis Medical College. 381 pages, handsomely illustrated. 
Price, $2.00 net. 
"For the use of the practitioner who, when away from home, has not the 

opportunity of consulting a library or of calling a friend in consultation. He 

then, being thrown upon his own resources, will find this book of benefit in 

guiding and assisting him in emergencies." 



CATALOGUE OF MEDICAL WORKS. 



HOW TO EXAMINE FOR LIFE INSURANCE. By John M. 
Keating, M. D., Fellow of the College of ■ Physicians and Surgeons of Phila- 
delphia; Vice-President of the American Pediatric Society; Ex-President 
of the Association of Life Insurance Medical Directors. Royal 8vo, 211 
pages, with two large half-tone illustrations, and a plate prepared by Dr. 
McClellan from special dissections ; also, numerous cuts to elucidate the text. 
Price, in Cloth, $2.00 net. 

" This is by far the most useful book which has yet appeared on insurance examination, a sub- 
ject of growing interest and importance. Not the least valuable portion of the volume is Part II., 
which consists of instructions issued to their examining physicians by twenty-four representative 
companies of this country. As the proofs of these instructions were corrected by the directors of 
the companies, they form the latest instructions obtainable. If for these alone the book should be 
at the right hand of every physician interested in this special branch of medical science.'' — The 
Medical News, Philadelphia. 

THE CARE OF THE BABY. By J. P. Crozer Griffith, M. D., Cleri- 
cal Professor of Diseases of Children, University of Pennsylvania ; Physician 
to the Children's Hospital, Philadelphia, etc. 392 pages, with 67 illustrations 
in the text, and 5 plates. i2mo. Price, $1.50. 

A reliable guide not only for mothers, but also for medical students and prac- 
titioners whose opportunities for observing children have been limited. 

" The whole book is characterized by rare good sense, and is evidently written by a master 
hand. It can be read with benefit not only by mothers, but by medical students and by any prac- 
titioners who have not had large opportunities for observing children." — American Journal of 
Obstetrics, July, 1895. 

" The best book for the use of the young mother with which we are acquainted. . . . There 
are very few general practitioners who could not read the book through with advantage." — Archives 
of Pediatrics, Aug., 1895. 

" No better book of its kind has come under our notice for some time. Although intended 
primarily for mothers and nurses, it will well repay perusal by medical students." — Birmingham 
Medical Review, Oct., 1895. 

" This is one of the best works of its kind that has been presented to the people for. many a 
day." — Maryland Medical Journal, Aug. 13, 1895. 

NURSING: ITS PRINCIPLES AND PRACTICE. By Isabel Adams 
Hampton, Graduate of the New York Training School for Nurses attached to 
Bellevue Hospital ; Superintendent of Nurses, and Principal of the Training 
School for Nurses, Johns Hopkins Hospital, Baltimore, Md. ; late Superin- 
tendent of Nurses, Illinois Training School for Nurses, Chicago, 111. In one 
very handsome i2mo volume of 484 pages, profusely illustrated. Price, 
Cloth, $2.00 net. 

This original work on the important subject of nursing is at once compre- 
hensive and systematic. It is written in a clear, accurate, and readable style, suit- 
able alike to the student and the lay reader. Such a work has long been a deside- 
ratum with those intrusted with the management of hospitals and the instruction 
of nurses in training-schools. It is also of especial value to the graduate nurse 
who desires to acquire a practical working knowledge of the care of the sick and 
the hygiene of the sick-room. 



22 W. B. SAUNDERS' ILLUSTRATED CATALOGUE. 

NURSE'S DICTIONARY of Medical Terms and Nursing Treat- 
ment, containing Definitions of the Principal Medical and Nursing Terms 
and Abbreviations ; of the Instruments, Drugs, Diseases, Accidents, Treat- 
ments, Physiological Names, Operations, Foods, Appliances, etc. encountered 
in the ward or in the sick-room. Compiled for the use of nurses. By 
Honnor Morten, Author of "How to Become a Nurse," "Sketches of 
Hospital Life," etc. i6mo, 140 pages. Price, Cloth, $1.00. 

This little volume is intended merely as a small reference-book which can be 
' onsulted at the bedside or in the ward. It gives sufficient explanation to the 
i . 1 1 rse to enable her to comprehend a case until she has leisure to look up larger 
a j id fuller works on the subject. 

DIET IN SICKNESS AND IN HEALTH. By Mrs. Ernest Hart, 
formerly Student of the Faculty of Medicine of Paris and of the London 
School of Medicine for Women ; with an Introduction by Sir Henry 
Thompson, F. R. C. S., M. D., London. 220 pages; illustrated. Price, 
Cloth, $1.50. 

Useful to those who have to nurse, feed, and prescribe for the sick. ... In 
each case the accepted causation of the disease and the reasons for the special 
diet prescribed are briefly described. Medical men will find the dietaries and 
recipes practically useful, and likely to save them trouble in directing the dietetic 
treatment of patients. 

" We recommend it cordially to the attention of all practitioners ; . . . . both to them and to 
their patients it may be of the greatest service." — Medical Journal, New York. 

DIETS FOR INFANTS AND CHILDREN IN HEALTH AND IN 
DISEASE. By Louis Starr, M. D., Editor of "An American Text- 
Book of the Diseases of Children." 230 blanks (pocket-book size), per- 
forated and neatly bound in flexible morocco. Price, $1.25 net. 

The first series of blanks are prepared for the first seven months of infant life ; 
each blank indicates the ingredients, but not the quantities, of the food, the latter 
directions being left for the physician. After the seventh month, modifications 
being less necessary, the diet lists are printed in full. Formula for the prepara- 
tion of diluents and foods are appended. 

DIET LISTS AND SICK-ROOM DIETARY. By Jerome B. Thomas, 
M. D., Visiting Physician to the Home for Friendless Women and Children 
and to the Newsboys' Home ; Assistant Visiting Physician to the Kings County 
Hospital; Assistant Bacteriologist, Brooklyn Health Department. Price, 
$1.50. Send for sample sheet. 

There is here offered, in portable form, as an efficient aid to the better practice 
of Therapeutics, a collection of detachable Diet Lists and a Sick-room Dietary. 
It meets a want, for the busy practitioner has but little time to write out Systems 
of Diet appropriate to his patients, or to describe the preparation of their food. 
Compiled from the most modern works on dietetics, the Dietary offers a variety 
of easily-digested foods. 

" A convenience that will be appreciated by the physician." — Medical Journal, New York. 

" The work is an excellent one, and ought to be welcomed by physician, patient, and nurse 
alike." — Indiari Lancet, Calcutta. 



Practical, Exhaustive. Authoritative. 



SAUNDERS' 

NEW AID SERIES OF MANUALS. 



FOR 



STUDENTS AND PRACTITIONERS. 



Mr. Saunders is pleased to announce the successful issue of several volumes 
of his NEW AID SERIES OF MANUALS, which have received the 
most flattering commendations from Students and Practitioners and 
the Press. As publisher of the Standard Series of Question Compends, 
and through intimate relations with leading members of the medical profession, 
Mr. Saunders has been enabled to study progressively the essential desiderata in 
practical " self-helps " for students and physicians. 

This study has manifested that, while the published "Question Compends" 
earn the highest appreciation of students, whom they serve in reviewing their 
studies preparatory to examination, there is special need of thoroughly reliable 
handbooks on the leading branches of Medicine and Surgery, each subject being 
compactly and authoritatively written, and exhaustive in detail, without the intro- 
duction of cases and foreign subject-matter which so largely expand ordinary text- 
books. 

The Saunders Aid Series will not merely be condensations from 
present literature, but will be ably written by well-known authors 
and practitioners, most of them being teachers in representative 
American Colleges. This new series, therefore, will form an admirable col- 
lection of advanced lectures, which will be invaluable aids to students in reading 
and in comprehending the contents of "recommended " works. 

Each Manual will further be distinguished by the beauty of the new type ; by 
the q aality of the paper and printing ; by the copious use of illustrations ; by the 
attractive binding in cloth; and by the extremely low price at which 

they will be sold. 

23 



Saunders' New Aid Series of Manuals. 



VOLUMES PUBLISHED. 



PHYSIOLOGY, by Joseph Howard Raymond, A. M., M. D., Professor of Physi- 
ology and Hygiene and Lecturer on Gynecology in the Long Island College Hos- 
pital ; Director of Physiology in the Hoagland Laboratory ; formerly Lecturer on 
Physiology and Hygiene in the Brooklyn Normal School for Physical Education ; 
Ex- Vice- President of the American Public Health Association ; Ex-Health Commis- 
sioner, City of Brooklyn, etc Illustrated. $1.25 net. 

SURGERY, General and Operative, by John Chalmers DaCosta, M. D., Demon- 
strator of Surgery, Jefferson Medical College, Philadelphia; Chief Assistant Sur- 
geon, Jefferson Medical College Hospital ; Surgical Registrar, Philadelphia Hospital, 
etc. 188 illustrations and 13 plates. (Double number.) $2.50 net. 

DOSE-BOOK AND MANUAL OF PRESCRIPTION-WRITING, by E. Q. 

Thornton, M. D., Demonstrator of Therapeutics, Jefferson Medical College, Phila- 
delphia. Illustrated. Price, cloth, $1.25 net. 

SURGICAL ASEPSIS, by Carl Beck, M. D., Surgeon to St. Mark's Hospital and 
to the New York German Poliklinik, etc. Illustrated. Price, cloth, $1.25 net. 

MEDICAL JURISPRUDENCE, by Henry C. Chapman, M. D., Professor of Insti- 
tutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of 
Philadelphia; Member of the College of Physicians of Philadelphia, of the Acade- 
my of Natural Sciences, of the American Philosophical Society, and of the Zoologi- 
cal Society of Philadelphia. Illustrated. #1.50 net. 

SYPHILIS AND THE VENEREAL DISEASES, by James Nevins Hyde, 
M.D., Professor of Skin and Venereal Diseases, and Frank H. Montgomery, 
M. D., Lecturer on Dermatology and Genito-Urinary Diseases, in Rush Medical 
College, Chicago. Profusely Illustrated. (Double number.) $2.50 net. 

PRACTICE OF MEDICINE, by George Roe Lockwood, M. D., Professor of 
Practice in the Woman's Medical College of the New York Infirmary ; Instructor 
of Physical Diagnosis of the Medical Department of Columbia College ; Attending 
Physician to the Colored Hospital; Pathologist to the French Hospital; Member 
of the New York Academy of Medicine, of the Pathological Society, of the Clinical 
Society, etc. Illustrated. (Double number.) $2.50 net. 

MANUAL OF ANATOMY, by Irving S. Haynes, M. D., Adjunct Professor of 
Anatomy and Demonstrator of Anatomy, Medical Department of the New York 
University, etc. Beautifully Illustrated. (Double number.) Price, $2.50 net. 

MANUAL OF OBSTETRICS, by W. A. Newman Dorland, M. D., Asst. Demon- 
strator of Obstetrics, University of Pennsylvania ; Chief of Gynecological Dispen- 
sary, Pennsylvania Hospital ; Member of Philadelphia Obstetrical Society, etc. 
Profusely illustrated. (Double number.) Price, $2.50 net. 

DISEASES OF WOMEN, by J. Bland Sutton, F. E. C. S., Asst. Surgeon to Mid- 
dlesex Hospital, and Surgeon to Chelsea Hospital, London ; and Arthur E. Giles, 
M. D., B. Sc. Lond., F. R. C. S. Edin., Asst. Surgeon to Chelsea Hospital, London. 
436 pages, handsomely illustrated. (Double number.) Price, $2.50 net. 



VOLUMES IN PREPARATION. 

NOSE AND THROAT, by D. Braden Kyle, M.D., Chief Laryngologist of the St. 
Agnes Hospital, Philadelphia; Bacteriologist of the Orthopaedic Hospital and 
'Infirmary for Nervous Diseases ; Instructor in Clinical Microscopy and Assistant 
Demonstrator of Pathology in the Jefferson Medical College, etc. 

NERVOUS DISEASES, by Charles W. Burr, M. D., Clinical Professor of Nervous 
Diseases, Medico-Chirurgical College, Philadelphia ; Pathologist to the Orthopaedic 
Hospital and Infirmary for Nervous Diseases ; Visiting Physician to the St. Joseph 
Hospital, etc. 

*#* There will be published in the same series, at close intervals, carefully-prepared works on 
various subjects, by prominent specialists. 

24 





SAUNDERS' QUESTION COMPENDS. 

Arranged in Question and Answer Form. 

THE LATEST, CHEAPEST, AND BEST ILLUSTRATED SERIES 
OP, COMPENDS EVER ISSUED. 



Now the Standard Authorities in Medical Literature 



Students and Practitioners in every City of the United States 

and Canada. 



THE REASON WHY 

They are the advance guard of " Student's Helps" — that do help; they are the leaders in 
their special line, well and authoritatively written by able men, who, as teachers in the large col- 
leges, know exactly what is wanted by a student preparing for his examinations. The judgment 
exercised in the selection of authors is fully demonstrated by their professional elevation. Chosen 
from the ranks of Demonstrators, Quiz-masters, and Assistants, most of them have become Pro- 
fessors and Lecturers in their respective colleges. 

Each book is of convenient size (5x7 inches), containing on an average 250 pages, profusely 
illustrated, and elegantly printed in clear, readable type, on fine paper. 

The entire series, numbering twenty-three volumes, has been kept thoroughly revised and 
enlarged when necessary, many of them being in their fourth and fifth editions. 

TO SUM UP. 

Although there are numerous other Quizzes, Manuals, Aids, etc. in the market, none of them 
approach the " Blue Series of Question Compends;" and the claim is made for the following points 
of excellence : 

1. Professional distinction and reputation of authors. 

2. Conciseness, clearness, and soundness of treatment. 

3. Size of type and quality of paper and binding. 

*** Any of these Compends will be mailed on receipt of price (see over for List). 

25 



26 W. B. SAUNDERS ILLUSTRATED 

Saunders' Question-Coiiipend Series. 

• <*,•> 

ji^° Price, Cloth, $1.00 per copy, except when otherwise noted. 



i. ESSENTIALS OF PHYSIOLOGY. 3d edition. Illustrated. Revised and enlarged. 
By H. A. Hare, M. D. (Price, $1.00 net.) 

2. ESSENTIALS OF SURGERY. 5th edition, with an Appendix on Antiseptic Surgery. 

90 illustrations. By Edward Martin, M. D. 

3. ESSENTIALS OF ANATOMY. 5th edition, with an Appendix. 180 illustrations. By 

Charles B. Nancrede, M. D. 

4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC. 

4th edition, revised, with an Appendix. By Lawrence Wolff, M. D. 

5. ESSENTIALS OF OBSTETRICS. 3d edition, revised and enlarged. 75 illustrations. 

By W. Easterly Ashton, M. D. 

6. ESSENTIALS OF PATHOLOGY AND MORBID ANATOMY. 6th thousand. 

46 illustrations. By C. E. Armand Semple, M. D. 

7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRE- 

SCRIPTION-WRITING. 4th edition. By Henry Morris, M. D. 

8. 9. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry Morris, M. D. 

An Appendix on Urine Examination. Illustrated. By Lawrence Wolff, M. D. 
3d edition, enlarged by some 300 Essential Formula?, selected from eminent authorities, 
by Wm. M. Powell, M. D. (Double number, price $2.00.) 

10. ESSENTIALS OF GYNECOLOGY. 3d edition, revised. With 62 illustrations. 

By Edwin B. Cragin, M. D. 

11. ESSENTIALS OF DISEASES OF THE SKIN. 3d edition, revised and enlarged. 

71 letter-press cuts and 15 half-tone illustrations. By Henry W. Stelwagon, M. D. 
(Price, $1.00 net.) 

12. ESSENTIALS OF MINOR SURGERY, BANDAGING, AND VENEREAL 

DISEASES. 2d edition, revised and enlarged. 78 illustrations. By Edward* 
Martin, M. D. 

13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. 

130 illustrations. By C. E. Armand Semple, M. D. 

14. ESSENTIALS OF DISEASES OF THE EYE, NOSE, AND THROAT. 124 

illustrations. 2d edition, revised. By Edward Jackson, M. D., and E. Baldwin 
Gleason, M. D. 

15. ESSENTIALS OF DISEASES OF CHILDREN. 2d edition. By William M. 

Powell, M. D. 

16. ESSENTIALS OF EXAMINATION OF URINE. Colored " Vogel Scale," 

and numerous illustrations. By Lawrence Wolff, M. D. (Price, 75 cents.) 

17. ESSENTIALS OF DIAGNOSIS. By S. Solis-Cohen, M. D., and A. A. Eshner, 

M. D. 55 illustrations, some in colors. (Price, $1.50 net.) 

18. ESSENTIALS OF PRACTICE OF PHARMACY. By L. E. Sayre. 2d edition, 

revised and enlarged. 

20. ESSENTIALS OF BACTERIOLOGY. 3d edition. 82 illustrations. By M. V. 
Ball, M. D. 

ai. ESSENTIALS OF NERVOUS DISEASES AND INSANITY. 48 illustrations. 
2d edition, revised. By John C. Shaw, M. D. 

22. ESSENTIALS OF MEDICAL PHYSICS. 155 illustrations. 2d edition, revised- 

By Fred J. Brockway, M. D. (Price, $1.00 net.) 

23. ESSENTIALS OF MEDICAL ELECTRICITY. 65 illustrations. By David D. 

Stewart, M. D., and Edward S. Lawrance, M. D. 

24. ESSENTIALS OF DISEASES OF THE EAR. By E. B. Gleason, M. D. 89 

illustrations. 



CATALOGUE OF MEDICAL WORKS. 27 

JUST PUBLISHED. 



A TEXT-BOOK OF MATERIA MEDICA, THERAPEUTICS, 
AND PHARMACOLOGY. By George F. Butler, Ph. G., M. D., 

Professor of Materia Medica and of Clinical Medicine in the College of 
Physicians and Surgeons, Chicago ; Professor of Materia Medica and Thera- 
peutics, Northwestern University, Woman's Medical School, etc. 8vo, 858 
pages. Illustrated. Prices : Cloth, $4.00 net ; Sheep or Half-Morocco, $5.00 net 

A clear, concise, and practical text-book, adapted for permanent reference no 
less than for the requirements of the class-room. The arrangement (embodying 
the synthetic classification of drugs based upon therapeutic affinities) is believed 
to be at once the most philosophical and rational, as well as that best calculated to 
engage the interest of those to whom the academic study of the subject is wont to 
offer no little perplexity. 

Special attention has been given to the Pharmaceutical section, which is 
exceptionally lucid and complete. 

LECTURES ON RENAL AND URINARY DISEASES. By 

Robert Saundby, M. D. Edin., Fellow of the Royal College of Physicians, 
London, and of the Royal Medico- Chirurgical Society; Physician to the 
General Hospital ; Consulting Physician to the Eye Hospital and to the 
Hospital for Diseases of Women ; Professor of Medicine in Mason College, 
Birmingham, etc. 8vo, 434 pages, with numerous illustrations and 4 colored 
plates. Price, Cloth, $2.50 net. 

In these Lectures, which are a re-issue in one volume of the author's well- 
known works on Bright' s Disease and Diabetes, there is given, within a modest 
compass, a review of the present state of knowledge of these important affections, 
with such additions and suggestions as have resulted from the author's thirteen 
years' clinical and pathological study of the subjects. The lectures have been 
carefully revised and much new matter added to them. There has also been added 
a section dealing with "Miscellaneous Affections of the Kidney," making the 
book more complete as a work of reference. 

ELEMENTARY BANDAGING AND SURGICAL DRESSING, 

with Directions concerning the Immediate Treatment of Cases of Emergency. 
For the use of Dressers and Nurses. By Walter Pye, F. R. C. S., late 
Surgeon to St. Mary's Hospital, London. Small i2mo, with over 80 illus- 
trations. Cloth, flexible covers. Price, 75 cents net. 

This little book is chiefly a condensation of those portions of Pye's " Surgical 
Handicraft" which deal with bandaging, splinting, etc., and of those which treat 
of the management in the first instance of cases of emergency. Within its own 
limits, however, the book is complete, and it is hoped that it will prove extremely 
useful to students when they begin their work in the wards and casualty rooms, 
and useful also to surgical nurses and dressers. 

"The directions are clear and the illustrations are good." — London Lancet. 

" The author writes well, the diagrams are clear, and the book itself is small and portable, 
although the paper and type are good." — British Medical Journal. 

" One of the most useful little works for dressers and nurses. The author truly says that it is < r 
very little book,' but it is large in usefulness." — Chemist and Druggist. 



JUST ISSUED. SOLD BY SUBSCRIPTION. 

ANOMALIES 

AND 

CURIOSITIES OF MEDICINE. 

BY 

GEORGE M. GOULD, M. D., 

AND 

WALTER L. PYLE, M. D. 

Several years of exhaustive research have been spent by the authors 
in the great medical libraries of the United States and Europe in col- 
lecting the material for this work. Medical literature of all ages 
and all languages has been carefully searched, as a glance at the 
Bibliographic Index will show. The facts, which will be of extreme 
value to the author and lecturer, have been arranged and anno- 
tated, and full reference footnotes given, indicating whence they have 
been obtained. 

In view of the persistent and dominant interest in the anomalous 
and curious, a thorough and systematic collection of this kind 
(the first of which the authors have knowledge) must have its own 
peculiar sphere of usefulness. 

As a complete and authoritative Book of Reference it will be 
of value not only to members of the medical profession, but to all 
persons interested in general scientific, sociologic, and medico-legal 
topics ; in fact, the general interest of the subject and the dearth of 
any complete work upon it make this volume one of the most 
important literary innovations of the day. 

An especially valuable feature of the book consists of the Indexing. 
Besides a complete and comprehensive General Index, containing 
numerous cross-references to the subjects discussed, and the names 
of the authors of the more important reports, there is a convenient 
Bibliographic Index and a Table of Contents. 

The plan has been adopted of printing the topical headings in 
bold-face type, the reader being thereby enabled to tell at a glance 
the subject-matter of any particular paragraph or page. 

Illustrations have been freely employed throughout the work, 
there being 165 relief cuts and 130 half-tones in the text, and 12 
colored and half-tone full- page plates — a total of over 320 separate 
figures. 

The careful rendering of the text and references, the wealth of illus- 
trations, the mechanical skill represented in the typography, the print- 
ing, and the binding, combine to make this book one of the most 
attractive medical publications ever issued. 



Handsome Imperial Octavo Volume of 968 Pages. 
PRICES: Cloth, $6.00 net; Half Morocco, $7.00 net. 



JUST ISSUED. 

PENROSE'S DISEASES OF WOMEN. 

A Text=Book of Diseases of Women. By Charles B. Penrose, M. D., Ph.D., Pro- 

fessor of Gynecology, University of Pennsylvania; Surgeon to the Gynecean Hospital, Phil- 
adelphia. Octavo volume of 529 pages, handsomely illustrated. Price, $3.50 net. 

MALLORY AND WRIGHT'S PATHOLOGICAL TECHNIQUE. 

Pathological Technique. By Frank B. Mallory, A. M., M. D., Asst. Professor of 
Pathology, Harvard University Medical School; and James H.Wright, A.M., M. D., 
Instructor in Pathology, Harvard University Medical School. Octavo volume of 396 pages, 
handsomely illustrated. 

SENN'S GENITOURINARY TUBERCULOSIS. 

Tuberculosis of the Genito= Urinary Organs, Male and Female. By Nicholas 
Senn, M. D., Ph.D., LL.D., Professor of the Practice of Surgery and of Clinical Surgery, 
Rush Medical College, Chicago. Handsome octavo volume of 320 pages. Illustrated. 

SUTTON AND GILES' DISEASES OF WOMEN. 

Diseases of Women. By J. Bland Sutton, F. R. C. S., Asst. Surgeon to Middlesex 
Hospital, and Surgeon to Chelsea Hospital, London; and Arthur E. Giles, M. D., B. Sc. 
Lond., F. R. C. S. Edin., Asst. Surgeon to Chelsea Hospital, London. 436 pages, hand- 
somely illustrated. Price, $2.50 net. 



IN PREPARATION. 

ANDERS' PRACTICE OF MEDICINE. 

A Text=Book of the Practice of Medicine. By James M. Anders, M. D., Ph.D., 

LL.D., Professor of the Practice of Medicine and of Clinical Medicine, Medico-Chirurgical 
College, Philadelphia. In press. 

AN AMERICAN TEXT=BOOK OF GENITO=URINARY AND SKIN DISEASES. 

Edited by L. Bolton Bangs, M. D., Late Professor of Genito-Urinary and Venereal Dis- 
eases, New York Post-Graduate Medical School and Hospital, and William A. Hard- 
away, M. D., Professor of Diseases of the Skin, Missouri Medical College. 

AN AMERICAN TEXT=BOOK OF DISEASES OF THE EYE, EAR, NOSE, AND 
THROAT. 

Edited by G. E. de Schweinitz, M. D., Professor of Ophthalmology in the Jefferson 
Medical College, and B. Alexander Randall, M. D., Professor of Diseases of the Ear 
in the University of Pennsylvania and in the Philadelphia Polyclinic. 

MACDONALD'S SURGICAL DIAGNOSIS AND TREATMENT. 

Surgical Diagnosis and Treatment. By J. W. Macdonald, M. D., Graduate of 
Medicine of the University of Edinburgh ; Licentiate of the Royal College of Surgeons, 
Edinburgh ; Professor of the Practice of Surgery and of Clinical Surgery, Minneapolis 
College of Physicians and Surgeons. 

HIRST'S OBSTETRICS. 

A Text=Book of Obstetrics. By Barton Cooke Hirst, M. D., Professor of Obstet- 
rics, University of Pennsylvania. 

MOORE'S ORTHOPEDIC SURGERY. 

A Manual of Orthopedic Surgery. By James E. Moore, M. D., Professor of 
Orthopedics and Adjunct Professor of Clinical Surgery, University of Minnesota, College 
of Medicine and Surgery. 

HEISLER'S EMBRYOLOGY. 

A Text=Book of Embryology. By John C. Heisler, M. D., Prosector to the Pro- 
fessor of Anatomy, Medical Department of the University of Pennsylvania. 



NOW READY— VOLUMES FOR 1896 AND 1897. 



+<z 



© 



•«6 



SAUNDERS' 

American Year-Book of Medicine and Surgery 

COLLECTED AND ARRANGED BY EMINENT AMERICAN SPECIALISTS AND TEACHERS, 

§ UNDER THE EDITORIAL CHARGE OF 

£ GEORGE M. GOULD, M. D. 

• 

8 Notwithstanding the rapid multiplication of medical and surgical works, 

p^ still these publications fail to meet fully the requirements of the general physician, 

? inasmuch as he feels the need of something more than mere text-books of well- 

^i known principles of medical science. Mr. Saunders has long been impressed with 

«b this fact, which is confirmed by the unanimity of expression from the profession 

^ at large, as indicated by advices from his large corps of canvassers. 

q This deficiency would best be met by current journalistic literature, but 

© most practitioners have scant access to this almost unlimited source of informa- 

^ tion, and the busy practiser has but little time to search out in periodicals the 

|» many interesting cases, whose study would doubtless be of inestimable value in his 

g practice. Therefore, a work which places before the physician in convenient form 
an epitomization of this literature by persons competent to pronounce upon 



§< The Value of a Discovery or of a Method of Treatment 



cannot but command his highest appreciation. It is this critical and judicial § 
•3 function that will be assumed by the Editorial staff of the " American Year-Book |£ 
^ of Medicine and Surgery." ^ 

It is the special purpose of the Editor, whose experience peculiarly qualifies § 
jS him for the preparation of this work, not only to review the contributions ? 
to American journals, but also the methods and discoveries reported in the g 
gi leading medical journals of Europe, thus enlarging the survey and making the g 
g work characteristically international. These reviews will not simply be a series r *. 

of undigested abstracts indiscriminately run together, nor will they be retro 
| spective of "news" one or two years old, but the treatment presented will be ^ 
^ synthetic and dogmatic, and will include only what is new. Moreover, through 
§ expert condensation by experienced writers, these discussions will be . 

Comprised in a Single Volume of about 1200 Pages. 
The work will be replete with original and selected illustrations skilfully 
reproduced, for the most part, in Mr. Saunders' own studios established for 
the purpose, thus ensuring accuracy in delineation, affording efficient aids to a 
right comprehension of the text, and adding to the attractiveness of the volume. 



Prices : Cloth, $6.50 net ; Half Morocco, $7.50 net. 

W. B. SAUNDERS, Publisher, 

925 Walnut Street, Philadelphia*? 



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